Development and implementation of school based physical activity interventions : a community-centred, co-designed approach

Regardless of the intensity or duration, engaging in regular physical activity has been consistently shown to lead to improvements in health and wellbeing. Exercise is known to improve quality of life and reduce mortality rates with minimal or no risk to safety. Promoting. It is associated with positive life outcomes, including better education, professional and financial outcomes, development of stronger social relationships and improved coping mechanisms and resilience. Participation in regular physical Activity is integral to population health and wellbeing.

In the UK during 2022-23 academic year, only 47% of children and young people aged 5-16 years met the recommended minimum guidelines for physical activity, meaning approximately 3.7 million children were inactive. A lower peak physical activity level during childhood and adolescence increases the risk of a physically inactive adulthood and poor health and life outcomes in the future. Promoting physical activity in childhood is therefore a vital public health need as it lays the foundation for peak physical fitness, establishes healthy attitudes and behaviours to exercise and provides long lasting physical, mental and social benefits.


Public health promotion requires the co-ordinated efforts of public health agencies, public sector and local councils, schools, community organisations and the private sector. These entities are empowered to design, implement and deliver interventions that directly address public health challenges, aiming to make policy goals a reality at local levels. These initiatives can range from national educational programmes to, local community-based interventions. Research suggests that school specific interventions should be well suited to promote physical activity.

Research shows that school based physical activity programs probably had little or no overall effect on minutes of moderate or vigorous physical activity per day but may lead to small improvements in physical fitness. Recommendations for future research in the area include a need for reporting the qualitative effects of interventions on health and wellbeing, factors considered to health equity and factors relating to intervention implementation including uptake and fidelity of adherence. Research should include community engagement initiatives in the design and implementation.

Patient involvement in research could be a useful strategy to promote uptake in short term behaviours and long-term maintenance of interventions. This is especially important in school based physical activity interventions. Schools are incredibly diverse institutions, varying greatly in their setting, ethos, management, staff, and sociodemographic factors. Interventions that are too tightly controlled and designed, and largely ignore the context in which the intervention is being developed and implemented may fail to align with the users needs, preferences, and the specific challenges they face. This could result in poor engagement, reduced effectiveness and reduce the likelihood of successful implementation.

Co-design research methodologies offer a potential solution to promote physical activity behaviours in school settings and address the gaps in the literature highlighted. They enable stakeholders to actively work together to analyse, design and implement solutions to defined problems. They are collaborative by nature, ensure empathic and contextual understanding and can lead to creative design through iterative and flexible processes. The flexibility of the methods enable behaviour science such as the Behaviour Change Wheel to be incorporated seamlessly into process providing a framework for understanding the factors that influence people’s choices and health behaviours.


In this thesis we aimed to develop healthy physical activity behaviours in primary school children in Stoke-on-Trent. It seeks to answer 3 questions:

1. Are children who are more physically active, healthier and performing better academically than those who are not?
2. What are parent’s attitudes to the use and effect of technology on children’s physical activity?
3. Can co-design methods enable pupils, staff and parents to design and implement a highly context specific, school based intervention to promote physical activity?

To answer these questions 5 studies were conducted. Two prospective cohort studies, a knowledge elicitation study, an intervention design study and an intervention evaluation.


Study 1 begins with an exploration of the effects of physical activity on children’s health and academic performance. It aims to identify if there was any association between physical activity, body mass and academic attainment. Physical activity status was determined using the Physical Activity Questionnaire – Children. Weight and height were measured, and BMI calculated at 4-time points. Academic attainment was measured from national standardised tests. It was found that Children who were less active demonstrated lower height, weight and BMI z-scores than children who are more active. They also had a higher rate of weight gain, than children who are more active and had greater fluctuations in weight, this could put them at risk of future weight and may be worth monitoring. Overall, it shows that children who were more active performed significantly better than children who are less active in writing and mathematics. However, as this study didn’t consider some of the common causes of poor health and wellbeing in highly deprived areas further research was indicated.

Study 2 built explored this topic further aiming to determine if this association is repeated and to identify differences in personal, social, and environmental factors that contribute to physical activity and academic attainment. In addition to the outcomes measured previously, we also considered nutrition, parents education and profession, family income and perception of their local environment. Findings from chapter 2 were confirmed as more active children demonstrated lower height, weight and BMI z-scores than children who are more active and experienced the same fluctuations in weight throughout the year. They also performed better in reading and mathematics than les active children. Although children’s parent’s profession was a factor in mathematics performances, physical activity levels remained a significant independent factor for health and academic performance.

Study 3 addressed research question 2. As it was a possibility that technology would be used as part of the later co-designed physical activity interventions, we conducted a survey of parent’s attitudes to the use and effect of technology on their children’s physical activity levels. A small majority of parents (53.3%) of respondents did not feel that technology use had an impact on the physical activity of their children compared to 46.7% who thought it had a negative effect. In those that did not feel it had a negative effect; they were more likely to report that their children enjoyed physical activity and were more likely to employ time limits to avoid overuse of technology. Those who felt it was negative were more likely to report their children preferred technology over being physical activity. This study emphasised the need to be cautious with the introduction of technology to support physical activity and support parents in the development of skills to mediate physical activity if used. It also encouraged the need to develop fun and enjoyable physical activity opportunities.

Findings from 1-3, were communicated to school staff, parents and pupils were important in establishing trust and a belief amongst the school setting senior management team, staff and parents that supporting the promotion of physical activity would have significant benefits. This set the scene for addressing research question 3 in Study 4 where an Evidence Based Co-Design approach was used to facilitate workshops where pupils, parents and staff came together to design their own, context specific physical activity intervention. Participants conducted an evaluation of physical activity in their school exploring capability, opportunity, and motivation to be active. They explored barriers and facilitators to be active from each of their own perspectives ensuring proactive solutions could be designed around identified factors. After the final design workshop, a daily walking group and after school exercise class was designed. This study demonstrated that Experience based co-design can be effective in developing tailored health interventions for schools that are responsive to local needs and stakeholder contexts. During the following academic year, the senior management team and school PE lead were empowered to independently implement the co-designed physical activity interventions. Support was offered from the research team as needed in terms of telephone and online meetings.

Study 5 describes the evaluation of the co-designed and independently implemented interventions. The APEASE criteria demonstrated that the interventions had high acceptability among pupils, parents and staff and all who participated wanted the interventions to continue in the longer term. A forecasted SROI indicated that every £1 spent would return value of £2.38 with potential benefits noted relating to improvements in health and wellbeing, quality of life, staff and student morale, student outcomes and the school environment noted. It showed that a co-designed physical activity intervention can be implemented in a school setting, offering increased opportunity to be physically activity and providing wider societal benefits. Early evaluation of behaviour change interventions are highly beneficial, supporting the wider implementation and disseminating findings to inform future practice and research.

Finally, a general discussion providing an overview of each of the studies and directly addresses each research question. Research findings are compared with the literature base, identifying the contributions to the is thesis makes to the overall evidence base. Implications for practice and research are identified and explained.

This thesis provides a valuable contribution to the fields of health promotion and childhood physical activity promotion in primary school settings. The value of physical activity in supporting health, well-being, and academic attainment is reinforced, highlighting the potential to transform the lives of children. Additionally, the research highlights the nuanced role of technology and its potential to detract from physical activity unless carefully integrated with parental support and guidance. It demonstrated that a highly tailored, context-specific intervention, that was highly acceptable and beneficial to the local community and those involved can be designed and implemented into school life, creating an environment where children, staff and parents can be more active on a daily basis