The Journal of School Nursing
2022, Vol. 38(1) 98–109© The Author(s) 2020 Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520972005journals.sagepub.com/home/jsn
The aim of this meta-ethnographic study was to analyze parents’ and teachers’ perceptions of barriers and facilitators to physical activity in children. Facilitators were the benefits of physical activity, modeling, participation, children’s preferences, and factors supporting active transport. Barriers were quantifying the physical activity, parents’ lack of time, the cost of activities, bad weather, traffic, long distances, and the lack of facilities and safety. The level of physical activity does not depend exclusively on individual factors related to the child; rather, barriers and facilitators are influenced by the social and school context and the physical and built environment. It is important that school nurses understand these contextual factors, so that they can take these into consideration when designing their intervention programs.
physical activity, preschooler, parents, schoolteachers, attitude, systematic review, qualitative research, school nurse
Overweight and obesity are defined as an abnormal and excessive accumulation of fat that can be harmful to health (World Health Organization [WHO], 2018). According to the latest data, worldwide in 2016, 39% of adults were overweight and 13% were obese (Organization for Economic Cooperation and Development [OECD], 2019). In addition, 340 million children and adolescents aged 5–19 and some 41 million children under 5 years old were overweight and obese (OECD, 2019).
The increase in overweight and obese children is a major public health problem as it is associated with physical and psychosocial health problems during both childhood and adulthood (Chooi et al., 2019; Hruby & Hu, 2015). In childhood, obesity is associated with the development of comorbidities such as high blood pressure, type 2 diabetes mellitus, nonalcoholic fatty liver, obstructive sleep apnea, or dyslipidemia (Kumar & Kelly, 2017; Martin-Espinosa et al., 2017). Furthermore, obesity is a cardiometabolic risk factor in adolescence and adulthood (Sardinha et al., 2016; Skinner et al., 2015) and may affect a child’s academic performance, self-esteem, and quality of life (Alvarez-Bueno, Pesce, Cavero-Redondo, Sánchez-López, Garrido-Miguel, & MartÃnez-VizcaÃno, 2017; Alvarez-Bueno, Pesce, Cavero-Redondo, Sánchez-López, Martinez-Hortelano, & Martinez-Vizcaino, 2017).
It is well known that obesity and overweight in adulthood are related to the body mass index (BMI) during childhood, where adiposity rebound, which occurs between 4 and 7–8 years, and the early adiposity rebound (between 3 and 5 years) are the predictive factors of obesity in adolescence and adulthood (Robinson et al., 2019; Rolland-Cachera et al., 1984, 2006; Taylor et al., 2005; Williams & Goulding, 2009). Therefore, it is necessary to consider variations in BMI during childhood, which may be determined by individual, contextual, or population factors, and to include children under the age of 5 at risk of early rebound in childhood obesity prevention programs, which traditionally begin at age 6 (Robinson et al., 2019; Roche et al., 2020; Wen et al., 2012).
Furthermore, in childhood, being overweight and obese can stem from a child’s exposure to an obese environment (Swinburn et al., 1999) and inadequate behavioral and biological responses to the environment, considered as predictors of obesity in adulthood (Lake & Townshend, 2006; Swinburn et al., 1999). The WHO recommends promoting initiatives that control intrinsic factors and modify obesogenic environments, such as comprehensive programs that promote physical activity and reduce sedentary behaviors, providing guidance and support for healthy diets, sleep patterns and physical activity during early childhood, or comprehensive programs that promote healthy school environments (WHO, 2017).
Family and school environments are important settings for promoting childhood health (Reilly et al., 2019). Behaviors associated with a healthy lifestyle in childhood may be influenced by a positive or negative parental model (Norton et al., 2003; O’Connor et al., 2009). In addition, the school is a good place to promote physical activity (Gray et al., 2019; Love et al., 2019). However, school-based physical activity interventions have not been effective in increasing children’s level of physical activity throughout the day, as measured using accelerometers (Love et al., 2019). Therefore, it is necessary to know the factors that influence the success of the interventions and the possible influence of the contextual factors that surround the child since it is difficult to achieve changes by focusing on only one environment, such as the school (Love et al., 2019).
Interventions aimed at preventing childhood obesity should consider all levels of the socioecological model, with special emphasis on parents, who should be targets for intervention, and on the organization and functioning of the school. Therefore, more research is needed to help identify which factors in the family and school environment contribute to obesity and the level of daily physical activity (Gray et al., 2019; Reilly et al., 2019).
To the best of our knowledge, no previous review has analyzed the influence of the environment on levels of physical activity in children at the age that adiposity rebound occurs and at the age that early adiposity rebound may occur. The aim of this review was to synthesize and analyze the available evidence on parents’ and teachers’ perceptions of barriers and facilitators to physical activity in children between the ages of 2 and 8.
A qualitative systematic review and meta-ethnography were carried out (Noblit et al., 1988). This method was chosen for its usefulness for the inductive synthesis of qualitative research and for the development of models to interpret the results of multiple studies, helping to generate a broader and more generalizable theory (Atkins et al., 2008; Campbell et al., 2011). The meta-ethnography consisted of the following stages: (1) getting started, (2) deciding what is relevant for initial interest, (3) reading the studies, (4) determining how the studies are related, (5) translating the studies among one another, (6) synthesizing the translations, and (7) expressing the synthesis (Noblit et al., 1988).
Thus, during Stages I and II, the meta-ethnography identified the study phenomenon and the relevant studies to be included. Stage III consisted of a critical and in-depth reading of all the studies included in the review to subsequently identify the interpretative metaphors or main concepts.
A systematic search was conducted on the MEDLINE (PubMed), Web of Science, CINAHL, Scopus, Cochrane Library Plus, ProQuest, and PsycINFO databases for qualitative articles published in English or Spanish, published at any time until January 1, 2020, that investigated parents’ or teachers’ perceptions of physical activity in school-age children between the ages of 2 and 8. In addition, we conducted a complementary gray literature search on Google Scholar, Open Gray, the DART-Europe E-theses Portal, Open Access Theses and Dissertations, and PQDT Open. This systematic review followed the proposal to improve the publication of systematic reviews and meta-analisys (PRISMA) statements (Urrútia & Bonfill, 2010) and the ENTREQ (Tong et al., 2012). The study protocol was registered in PROSPERO (CRD42017057852).
The search for potential articles was carried out independently, and later by consensus, by two reviewers (VAP and BRM) who followed the protocol, whereas a third reviewer mediating any disagreements. The search strategy included a combination of terms adapted according to the database analyzed (Supplemental Table 1). In addition, we conducted a secondary search by checking the references of the selected articles.
The articles were independently selected by the two reviewers according to the inclusion and exclusion criteria and subsequently agreed upon. First, a selection was made by title and abstract and then the full text of the articles that met the inclusion criteria was reviewed. The following inclusion criteria were followed: (1) articles that analyzed the perceptions, opinions, conceptualizations, or views of parents or teachers on physical activity in children aged 2–8; (2) items that specified that the children were enrolled in preschool or elementary school; (3) articles published in English or Spanish; and (4) articles that used qualitative methodology including primary or secondary data. The exclusion criteria used were as follows: (1) articles that analyzed the perceptions of parents or teachers of children under 2 years of age enrolled in preschool since from this age onward, many of the gross motor skills are acquired; (2) articles that also analyzed perceptions of childhood obesity, food, or nutrition in childhood and did not perform a disaggregated analysis; (3) articles that analyzed children’s perceptions of their own physical activity; (4) articles that included children with functional diversity or physical or mental pathology in their sample; and (5) conference proceedings or gray literature that did not contain the full published qualitative studies or that lacked the participants’ verbalizations.
Despite the controversy surrounding the quality appraisal of qualitative studies (Eakin & Mykhalovskiy, 2003), studies must provide an adequate description of the concepts and be methodologically sound (Campbell et al., 2011; Toye et al., 2013). We used the CASPe tool for qualitative studies, without using the quality analysis of the studies as an inclusion or exclusion criterion, but rather to provide information on their methodological quality (Cano Arana et al., 2010). Two authors (VAP and BRM) independently assessed study quality, resolving disagreements by consensus (Supplemental Table 2).
An inductive analysis of the results of the primary studies and the original authors’ interpretations was carried out. Data analysis was supported using the ATLAS.ti 7.5.15 qualitative analysis software.
During Stage IV, the studies were reread and their results were analyzed in their language of publication. One of the researchers (VAP) performed a line-by-line coding of the content of the studies, which enabled relationships to be established between them. Both first-order and secondorder quotations were coded. In Stage V, and for the reciprocal translation, two researchers (VAP and BRM) were in charge of carrying out a provisional comparison of the codes identified in the previous phase. The constant comparison method was used in order to find similarities and contradictions between the codes. The codes were grouped by areas of similarity, resulting in the different themes, categories, and subcategories of facilitators and barriers to physical activity of school-aged children. For the translation of the studies, the data were exported to a table containing the topic tree, categories, subcategories, codes, and citations, helping to understand the relationships between the studies. No refutations nor contradictions were found, as the data from all included studies were very similar. In Stage VI, the researchers compared the translations to identify the lines of argument based on which the synthesis would be developed.
After searching the databases, 2,989 articles were found, with 333 duplicates in various databases, leaving 2,656. After screening by title and abstract, the full text of 180 articles was reviewed. The gray literature search did not yield any studies that met the inclusion criteria. Finally, 21 articles were included in the meta-ethnography (Bellows et al., 2008; Bentley et al., 2012; Bowles & O’Sullivan, 2012; Copeland et al., 2012; De Craemer et al., 2013; De Decker et al., 2013; Dwyer et al., 2008; Edwards et al., 2015; Eyler et al., 2008; Grzywacz et al., 2016; Hessler, 2009; Hinkley & McCann, 2018; Irwin et al., 2005; Lindsay et al., 2018; Loucaides & Chedzoy, 2005; Neely & Holt, 2014; Pesch et al., 2015; Tucker et al., 2011; Webster et al., 2017; Zahra et al., 2015; Zuniga, 2012; Figure 1).
All the papers analyzed were published between 2005 and 2018, featuring the perceptions of 1,402 parents and 422 teachers regarding the physical activity of school-age children across different countries. Supplemental Table 3 features the methodological characteristics of the included studies.
Three main themes emerged from the thematic synthesis: facilitators and barriers to physical activity and areas of improvement perceived by parents and teachers for the promotion of physical activity in children. Facilitators were considering physical activity as beneficial; social context factors, such as parent–teacher modeling and partnership; physical and community environment factors, such as availability of space, living in rural areas, or residing in large homes; children’s preferences; and factors supporting active transport, such as economic savings or taking advantage of walks to spend time together. The barriers identified were the difficulty in quantifying children’s physical activity; social context factors, such as parental workload, lack of time, and having to care for several children; physical and community environment barriers, such as unfavorable weather conditions, lack of space and facilities for physical activity, and lack of safety; and factors that make active transport difficult, such as heavy traffic, long distances, or preference for using the car (Supplemental Tables 4–6).
Considering physical activity as beneficial. The participants in the studies perceived that physical activity was beneficial for physical health as well as on a psychological, emotional, and social level, considering that the practice of physical activity increased children’s physical fitness (Copeland et al., 2012; De Decker et al., 2013; Dwyer et al., 2008; Grzywacz et al., 2016; Hinkley & McCann, 2018; Neely & Holt, 2014) and helped them maintain an active lifestyle by acquiring healthy habits (Copeland et al., 2012; Hinkley & McCann, 2018; Neely & Holt, 2014). The participants considered that it is important for children to have an active lifestyle, controlling sedentary behaviors. They expressed their concern about childhood obesity and highlighted the prevention of obesity and other childhood diseases as one of the greatest benefits of physical activity (Copeland et al., 2012; Dwyer et al., 2008; Grzywacz et al., 2016; Hinkley & McCann, 2018).
The psychological and emotional benefits were considered as an important element in encouraging physical activity among schoolchildren (Bowles & O’Sullivan, 2012; Copeland et al., 2012; Dwyer et al., 2008; Hinkley & McCann, 2018; Neely & Holt, 2014). Parents and teachers pointed out that physical activity contributed to the development of the brain, increasing creativity, improving mood, and achieving a state of calm, thanks to the release of energy and the reduction in tension and stress, impacting on wellbeing and improving children’s self-perception, selfconfidence, and sense of achievement.
According to the participants, physical activity and play were facilitating elements of social integration and socialization among children (Bowles & O’Sullivan, 2012; Copeland et al., 2012; Dwyer et al., 2008; Hessler, 2009; Hinkley & McCann, 2018; Neely & Holt, 2014). Some participants expressed that, through the practice of sports, children acquired cooperation and teamwork skills, increasing their sense of belonging to a group and learning social norms (Bowles & O’Sullivan, 2012).
Social context factors that support physical activity. The main facilitators of physical activity identified were parental modeling (Bellows et al., 2008; De Craemer et al., 2013; Dwyer et al., 2008; Hessler, 2009; Loucaides & Chedzoy, 2005; Tucker et al., 2011; Zahra et al., 2015) and teachers modeling (Copeland et al., 2012; De Craemer et al., 2013; Dwyer et al., 2008; Webster et al., 2017). Parents and teachers felt that they could be role models, perceiving that the more active they were, the more active the children would be. Another facilitator was co-participation, thus parents considered it important to carry out activities with their children to encourage them to be physically active (Bellows et al., 2008; De Craemer et al., 2013; Dwyer et al., 2008; Loucaides & Chedzoy, 2005; Tucker et al., 2011; Zahra et al., 2015; Zuniga, 2012). They also perceived that watching television was harmful to children and they preferred to limit their viewing time (Grzywacz et al., 2016; Hinkley & McCann, 2018; Loucaides & Chedzoy, 2005). Some teachers felt that integrating movement into their classes and implementing programs with this goal could increase the physical activity level of schoolchildren (Webster et al., 2017). As for the influence of siblings and friends, peer support could increase children’s activity level (Bentley et al., 2012; Dwyer et al., 2008; Edwards et al., 2015; Grzywacz et al., 2016; Irwin et al., 2005; Loucaides & Chedzoy, 2005; Zuniga, 2012). Thus, when children with siblings or friends attended certain activities that involved exercise or movement, they were more likely to want to participate as well (Bentley et al., 2012; Irwin et al., 2005). Parents noted that friends influenced the type of activities their children chose and facilitated active play outside the home.
Physical and community environment facilitators. Participants felt that factors in the physical or community environment, such as the availability of space for physical activity, living in rural areas, the size of the household, and favorable weather conditions, could encourage physical activity. Regarding the availability of spaces for physical activity, they considered that children living in rural areas had more outdoor space than those living in urban areas, supporting physical activity (Bellows et al., 2008; Copeland et al., 2012; De Craemer et al., 2013; De Decker et al., 2013; Dwyer et al., 2008; Grzywacz et al., 2016; Lindsay et al., 2018; Webster et al., 2017). In addition, participants felt that large or courtyard/garden homes facilitated physical activity versus small homes. Teachers felt that having ample space at school, appropriate equipment and materials, and the presence of sufficient supervisory personnel facilitated physical activity among children. The weather conditions, and in particular, the good weather was a further facilitator, considering that the heat made it easier for the children to go out and be more active (Bellows et al., 2008; Copeland et al., 2012; De Craemer et al., 2013; De Decker et al., 2013; Dwyer et al., 2008; Grzywacz et al., 2016; Irwin et al., 2005; Zuniga, 2012).
Children’s individual preferences and factors. Parents and teachers felt that the child’s personality influenced their activity level (Dwyer et al., 2008; Edwards et al., 2015). Children’s preferences and priorities were also perceived as facilitators for physical activity (Bentley et al., 2012; Copeland et al., 2012; De Decker et al., 2013; Dwyer et al., 2008; Irwin et al., 2005; Webster et al., 2017). Parents and teachers agreed on the children’s preference for outdoor and movement activities. When choosing organized activities, there were sometimes discrepancies between the parents’ and children’s preferences, although in general, the participants reported that the children preferred to be active (Bentley et al., 2012). In addition, in one study, participants noted that when children had a very high interest in activities, they were less sedentary (De Decker et al., 2013).
In relation to the children’s age, participants indicated that young children tended to be more active because they had higher energy levels (De Decker et al., 2013; Irwin et al., 2005), although some felt that some children were more active in the classroom and more sedentary in the playground (De Decker et al., 2013). Regarding gender (De Decker et al., 2013; Dwyer et al., 2008; Loucaides & Chedzoy, 2005; Zahra et al., 2015), boys tended to be more active than girls, with girls in some cases preferring to play at home while boys preferred to play in the open air. In addition, being a boy or a girl influenced parents’ behavior by preferring boys to do sport-related activities and girls to do activities considered more “feminine,†such as ballet.
Factors supporting active transport. Facilitators for active transport were the economic savings of walking or cycling by not spending money on fuel; the associated benefits of the same, such as reduced sedentarism and obesity, encouraging energy expenditure in children or building healthy habits. Some participants considered that walking to school was a good opportunity to share time with children, get to know the neighborhood and other people, promoting a sense of belonging to a community (Eyler et al., 2008; Tucker et al., 2011; Zuniga, 2012).
Difficulty in quantifying children’s physical activity. The difficulty of objectively measuring physical activity and the parents’ perception that high activity levels were a problem were perceived as barriers to physical activity during childhood (Bentley et al., 2012; De Craemer et al., 2013; Dwyer et al., 2008; Grzywacz et al., 2016; Irwin et al., 2005; Pesch et al., 2015). Many parents felt that their children were already active enough since young children are constantly on the move. Only a small number of parents felt that their children were not active enough (Bentley et al., 2012; Lindsay et al., 2018). Some parents were concerned about the difficulty they had in their ability to measure their children’s physical activity level in the absence of an objective measurement system (Bentley et al., 2012; Dwyer et al., 2008), generating confusion and doubt about whether the level of activity they perceived could be adequate or not.
The teachers considered that inside the school, the children were very active and found it difficult to remain seated inside the classroom. However, they considered that at home, children were not very active and that outside school hours, passive or sedentary activities and games predominated among the children (Bentley et al., 2012; De Craemer et al., 2013; Dwyer et al., 2008; Irwin et al., 2005; Pesch et al., 2015). Parents considered that high levels of physical activity was a problem (Grzywacz et al., 2016; Hinkley & McCann, 2018; Lindsay et al., 2018; Pesch et al., 2015), which could be harmful to children’s health. In one study, participants expressed that overprotective parenting behaviors could limit children’s active behaviors (Dwyer et al., 2008). Some mothers reported setting limits on their children’s physical activity, suggesting less stimulating or sedentary activities (Pesch et al., 2015).
Social context factors that limit physical activity. The main barriers identified were the parents’ priorities (Bentley et al., 2012), promoting activities aimed at increasing educational or academic achievement (Dwyer et al., 2008; Zahra et al., 2015) and the belief that sedentary activities and computer use were good for children by benefiting their cognitive development or learning (Grzywacz et al., 2016; Hinkley & McCann, 2018).
Parents’ lack of time, their workload, and having to care for several children were barriers to the children’s physical activity (Bentley et al., 2012; De Craemer et al., 2013; Dwyer et al., 2008; Grzywacz et al., 2016; Irwin et. al, 2005; Loucaides & Chedzoy, 2005; Zahra et al., 2015; Zuniga, 2012). Both parents and teachers highlighted the trend of children being over busy (Dwyer et al., 2008; Zuniga, 2012). Thus, under pressure to improve academic performance, they enrolled children in many extracurricular activities that were limiting and hindered active free play. On the other hand, participants felt that cultural values (Bowles & O’Sullivan, 2012; Dwyer et al., 2008; Zuniga, 2012), parents’ gender (Zahra et al., 2015), and gender stereotypes could influence children’s physical activity.
According to the teachers, factors such as bad weather, the workload involved in preparing materials for outdoor activities or administrative tasks, helping children put on warm clothes or applying sunscreen, their own illnesses, or their preference for staying with the children in the classroom could limit the children’s activity level (Copeland et al., 2012; Webster et al., 2017).
Regarding the influence of siblings and friends, participants noted that siblings had more influence on informal play, such as going to the park, playing in the garden, or riding a bicycle. They also noted that older siblings may have encouraged young children to engage in sedentary activities such as playing video games or co-viewing television programs (Bentley et al., 2012; Dwyer et al., 2008; Edwards et al., 2015; Grzywacz et al., 2016; Irwin et al., 2005; Loucaides & Chedzoy, 2005; Zuniga, 2012).
Barriers in the physical and community environment. The lack of space in the home (Bellows et al., 2008; De Craemer et al., 2013; Grzywacz et al., 2016) and at school and the shortage of staff and safe play areas were obstacles to physical activity (Copeland et al., 2012; De Craemer et al., 2013; De Decker et al., 2013; Lindsay et al., 2018; Webster et al., 2017). In addition, weather conditions could make it difficult for children to be physically active (Bellows et al., 2008; Copeland et al., 2012; De Craemer et al., 2013; De Decker et al., 2013; Dwyer et al., 2008; Grzywacz et al., 2016; Irwin et al., 2005; Zuniga, 2012). Thus, the cold or bad weather limited the children from going out to play in the street or in the schoolyard. Participants expressed concern about the safety of children outside the home, saying that traffic, distance from home to school, lack of safe spaces, perceiving the environment as dangerous, fear of children being abducted, or of injury were perceived as barriers to physical activity and children’s free play (Bellows et al., 2008; Bentley et al., 2012; De Craemer et al., 2013; Dwyer et al., 2008; Grzywacz et al., 2016; Hinkley & McCann, 2018; Loucaides & Chedzoy, 2005; Zuniga, 2012). Some parents felt that the lack of facilities and the low supply of organized physical activity activities, especially in rural settings (Bentley et al., 2012; Dwyer et al., 2008; Hessler, 2009; Loucaides & Chedzoy, 2005), and its high cost could be barriers to children’s physical activity (Bentley et al., 2012; De Craemer et al., 2013; Dwyer et al., 2008; Irwin et al., 2005; Loucaides & Chedzoy, 2005; Zuniga, 2012).
Factors that make active transport difficult. Parents and teachers highlighted the following factors that limited active travel: the distance between home and schools or sports clubs; parents’ working conditions and the lack of time that forced them to use the car more frequently than desired; the perceived lack of safety of the environment; traffic, the presence of distracted drivers, incorrect road signs, or the absence of pedestrian crossings; fear of injury, falls, and the poor condition of pavements; adverse weather conditions, and heavy backpacks that children had to carry (Bentley et al., 2012; De Craemer et al., 2013; Dwyer et al., 2008; Eyler et al., 2008; Grzywacz et al., 2016; Loucaides & Chedzoy, 2005; Zuniga, 2012).
Increased collaboration between parents and teachers. Some of the teachers felt that children’s level of physical activity could be increased by making parents aware of its associated benefits and informing them of the activities they could carry out in their neighborhoods via workshops or outreach activities. Also, it was considered that involving parents in school activities could be positive (Bellows et al., 2008; De Craemer et al., 2013; Tucker et al., 2011; Zuniga, 2012).
Strategies to promote an active and healthy lifestyle. To encourage active behaviors in children, participants proposed to promote transport and active tourism (Eyler et al., 2008; Zuniga, 2012), restricting the hours of watching television or playing video games (De Decker et al., 2013; Dwyer et al., 2008; Hinkley & McCann, 2018; Loucaides & Chedzoy, 2005). Some parents stressed the importance of encouraging healthy behaviors at early ages (Irwin et al., 2005), stating that establishing physical activity patterns from preschool onward may favor the development of an active lifestyle in the long term.
Strategies for increasing physical activity at school. Some teachers felt that the creation of spaces for physical activity (Dwyer et al., 2008; Webster et al., 2017), both in and out of school, and implementing programs to integrate movement into the classroom would facilitate physical activity among children (Webster et al., 2017).
Strategies for increasing parent training in physical activity. According to parents, receiving information about children’s physical activity through public health campaigns in the media, or via the advice given by health professionals, contact with other parents, teachers, or people around them and through social networks and the internet was beneficial and a positive mechanism to facilitate physical activity (De Craemer et al., 2013; Lindsay et al., 2018). In one study, mothers used the internet to gather more information, considering it important to establish digital literacy strategies to facilitate the search for information (Lindsay et al., 2018). Policy guidelines on physical activity were often unknown; participants felt that it would be necessary to provide information to parents on this subject, which would help increase their children’s activity level. In addition, they perceived that it would be good to have government funding and support to develop programs that promote physical activity during childhood (Dwyer et al., 2008; Eyler et al., 2008; Hinkley & McCann, 2018; Irwin et al., 2005).
This meta-ethnography shows that according to parents and teachers, elements such as the benefits attributed to the practice of physical activity, the modeling of parents and teachers, the support of friends and siblings, co-participation, the availability of appropriate spaces and facilities, the type of activities preferred by the children, and the factors supporting active transport act as facilitators of the context, increasing the level of activity in childhood. In contrast, the difficulty in quantifying children’s physical activity, parental workload, lack of time, cost of activities, bad weather, lack of facilities for physical activity, lack of safety, heavy traffic, long distances, or preference for using the car have the opposite effect, acting as contextual barriers and decreasing the level of children’s activity (Bellows et al., 2008; Bentley et al., 2012; Bowles & O’Sullivan, 2012; Copeland et al., 2012; De Craemer et al., 2013; De Decker et al., 2013; Dwyer et al., 2008; Edwards et al., 2015; Eyler et al., 2008; Grzywacz et al., 2016; Hessler, 2009; Hinkley & McCann, 2018; Irwin et al., 2005; Lindsay et al., 2018; Loucaides & Chedzoy, 2005; Neely & Holt, 2014; Pesch et al., 2015; Tucker et al., 2011; Webster et al., 2017; Zahra et al., 2015; Zuniga, 2012).
Our results follow the line of other studies that show that regular physical activity is beneficial to children’s health by improving fitness, preventing cardiovascular disease, type 2 diabetes, and high blood pressure, or reducing obesity and overweight (Kumar & Kelly, 2017; Martin-Espinosa et al., 2017; Sardinha et al., 2016; Skinner et al., 2015). It can also improve psychological well-being, academic performance, cognition, and metacognition (Alvarez-Bueno, Pesce, Cavero-Redondo, Sánchez-López, Martinez-Hortelano, et al., 2017; Mavilidi et al., 2019). Other studies conclude that increasing training of parents and teachers on the benefits of regular physical activity can improve children’s activity (Reilly et al., 2019). Although our results highlight parents’ belief that young children are already active enough, other research concludes that the amount of physical activity perceived by parents and that performed by school-aged children is not consistent with the recommendations of 180 min of physical activity throughout the day, of which 60 min per day should be moderate and/or vigorous activity in children under age 5 and 60 min per day of moderate or vigorous physical activity in children aged 6 and older (WHO, 2010, 2019). As reflected in our findings, this may be due to the difficulty parents have in objectively measuring their children’s physical activity. It is necessary to continue studying this issue in depth since the papers analyzed do not describe the specific difficulties encountered by parents and teachers when objectifying the level of physical activity of their children, nor do they clarify whether parents and teachers are able to differentiate between the different levels of physical activity. This information would help guide strategies aimed at decreasing the differences between the actual amount of daily physical activity performed by children versus the perceived physical activity.
Most of the studies analyzed consider that the social context of schoolchildren has a positive or negative influence on their physical activity. Social support and the influence of parents, teachers, siblings, and friends can be both facilitators and barriers to physical activity, and previous studies agree that family, peers, and teachers are important socializing elements that support the practice of physical activity (Goh et al., 2017; Laird et al., 2018; Shen et al., 2018; Yao & Rhodes, 2015). In addition, our results are consistent with other research that confirms that children’s beliefs about the support of these socializing agents can help shape their attitudes, values, and participation in physical activity (Bois et al., 2005; Brustad, 1993; Freire et al., 2018; Ornelas et al., 2007; Shen et al., 2018) and that co-participation allows parents to shape healthy behaviors, convey to children the importance of being active (Rhodes & Lim, 2017), and facilitate parenting by teaching important life skills (Freire et al., 2018).
Studies show that although parents are motivated for their children to practice a healthy lifestyle, often, these behaviors do not emerge, and therefore, it is necessary to overcome barriers that may frustrate them in the future (Hamilton et al., 2014; Hamilton & Schwarzer, 2018; Rhodes & Lim, 2017). We know that when parents perceive many barriers for performance and believe it is difficult to engage their children in regular physical activity, they are less likely to decide to engage in these types of activities to keep their children active (Hamilton et al., 2014). Furthermore, it is important for school nurses to understand the potential influence of parents on physical activity, as this information is key to the development of programs aimed at the prevention of childhood obesity and overweight (Hutchens & Lee, 2018). Therefore, it is important to understand parents’ beliefs and decision making in order to develop strategies and programs that help control these barriers and increase children’s levels of physical activity (Hamilton et al., 2016).
Our results coincide with previous studies that show that aspects of the built environment such as the lack of appropriate facilities for walking or cycling, the lack of parks and recreational facilities, the lack of sidewalks, bike paths, steeply rising streets, the lack of space within the school, and of elements to facilitate the integration of movement within the classrooms act as barriers to physical activity (Goh et al., 2017; Michael et al., 2019; Mitchell et al., 2016; Wang et al., 2016). Improving the urban landscape to increase walkability and bicycle use, improving intersections and sidewalks, building bicycle parking lots and bike lanes, installing traffic control devices, increasing the quality of parks, including new equipment, building walking trails, eliminating benches, and providing adequate infrastructure to facilitate active transport (Smith et al., 2017) or adapt the configuration of the schoolyard are the elements that promote physical activity (Reilly et al., 2019).
As other studies have pointed out, our results show that teachers can facilitate physical activity by implementing programs and policies that integrate movement in the classroom and school (Goh et al., 2017; Michael et al., 2019). However, despite their benefits, most schools do not have these programs (Nathan et al., 2018, 2019). We have found a smaller number of studies that focus on the analysis of contextual factors related to the school or that contemplate teachers’ perceptions. Since the number of hours that children spend in the school environment is high, it would be appropriate for future research to further analyze these factors.
The results of this review show a certain lack of knowledge among parents and teachers regarding school policies to implement strategies to promote physical activity, considering that it is necessary to increase government aid and funding for such purposes, while providing more extensive education and training in the subject. Our results are consistent with previous studies that show that training, education, and modeling of the different social agents surrounding the child, their parents, environmental restructuring, and reinforcement, such as the presence of financial incentives to increase physical activity, are important aspects of implementing programs that promote physical activity during childhood (Reilly et al., 2019).
To the best of our knowledge, this is the only metaethnography that analyzes barriers and facilitators for school-age children’s physical activity from the perspective of both parents and teachers.
In relation to the limitations, a smaller number of studies were found to analyze the perceptions of teachers or the school environment, as opposed to those analyzing the perceptions of parents. Therefore, it would be interesting to continue to explore the factors related to the children’s school context, which may influence their physical activity. In addition, future studies should analyze whether there are differences in perceptions according to the age of the schoolchildren or the influence of the academic curriculum and the weight or value given to the physical education subject or the actual difficulties present in the school context for the implementation of movement-based methodologies.
The publication bias and the fact that only articles in English and Spanish were included in the databases analyzed constitute further limitations. In addition, it is worth noting that we encountered difficulties retrieving all the gray literature on the subject, meaning that other potential relevant studies could have been excluded in this analysis.
Moreover, the heterogeneity of the samples included in the studies is a limitation, which has prevented us from performing a more in-depth analysis of the sociodemographic characteristics that could have influenced these findings, such as the socioeconomic condition and/or the gender of parents, teachers, and the schoolchildren themselves. Further studies are needed to further investigate each of the identified facilitators and barriers to physical activity and to analyze this phenomenon in other specific contexts.
This study illustrates the barriers and facilitators for schoolchildren’s physical activity, as perceived by parents and teachers. This information is key for nurses to incorporate into health promotion and disease prevention programs and strategies in the school setting, especially those related to obesity, overweight, or sedentary lifestyles. This enables the focus to be placed on the children’s context and family rather than being limited to just the schoolchildren themselves.
The perceptions, behaviors, and attitudes of both parents and teachers and the context surrounding the child influence the physical activity of schoolchildren. Factors such as parent– teacher modeling, co-participation in activities, children’s preferences, availability of play spaces, good weather, residing in rural areas or large homes can increase children’s physical activity. Meanwhile, parents’ lack of time, the cost of organized activities, lack of motivation among teachers, perceived lack of safety in the neighborhood, and the presence of traffic can limit children’s physical activity.
These factors should be considered when developing interventions to increase the level of physical activity among schoolchildren in order to meet the global recommendations for the amount of daily physical activity in children and to support a healthy lifestyle throughout childhood and adulthood.
Vanesa Alcántara Porcuna contributed to conception or design and acquisition, analysis, or interpretation; drafted the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Beatriz RodrÃguez-MartÃn contributed to conception or design and acquisition, analysis, or interpretation; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research and/or authorship of this article.
Vanesa Alcántara Porcuna, PhDc, MSc, OTR https://orcid.org/0000-0001-5716-2236
Beatriz RodrÃguez-MartÃn, PhD, MSc, RN https://orcid.org/0000-0003-3939-0299
Supplemental Material for this article is available online.
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Vanesa Alcántara Porcuna, PhDc, MSc, OTR, is a Teaching Assistant at the Faculty of Health Sciences, University of Castilla–La Mancha, Toledo, Spain.
Beatriz RodrÃguez-MartÃn, PhD, MSc, RN, is a Professor at the Faculty of Health Sciences, University of Castilla La Mancha, Toledo, Spain and Social and Health Research Center, University of Castilla–La Mancha, Cuenca, Spain.
1 Faculty of Health Sciences, University of Castilla–La Mancha, Toledo, Spain
2 Social and Health Research Center, University of Castilla–La Mancha, Cuenca, Spain
Corresponding Author:Vanesa Alcántara Porcuna, PhDc, MSc, OTR, Faculty of Health Sciences, University of Castilla–La Mancha, Talavera de la Reina, Toledo 45600, Spain.Email: vanesa.alcantara@uclm.es
