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A systematic review and meta-analysis ofmoderate-to-vigorous physical activitylevels in secondary school physicaleducation lessonsJenna L. Hollis1,2*, Rachel Sutherland1,2,3, Amanda J. Williams1,2,3, Elizabeth Campbell1,2,3, Nicole Nathan1,2,3,Luke Wolfenden1,2,3, Philip J. Morgan4, David R. Lubans4, Karen Gillham1,2 and John Wiggers1,2,3
Abstract
Background: Schools play an important role in physical activity promotion for adolescents. The systematic reviewaimed to determine the proportion of secondary (middle and high) school physical education (PE) lesson time thatstudents spend in moderate to vigorous physical activity (MVPA), and to assess if MVPA was moderated by schoollevel (middle and high school), type of physical activity measurement and type of PE activities.
Methods: A systematic search of nine electronic databases was conducted (PROSPERO2014:CRD42014009649).Studies were eligible if they were published between 2005 and 2014; written in English; assessed MVPA in PE lessons ofsecondary (middle and high) school students; and used a quantitative MVPA measure (i.e., accelerometry, heart ratemonitoring, pedometers or observational measures). Two reviewers examined the retrieved articles, assessed risk of bias,and performed data extraction. Random effects meta-analysis was used to calculate a pooled estimate of the percent ofPE lesson time spent in MVPA and to assess moderator effects where data allowed.
Results: The search yielded 5,132 potentially relevant articles; 28 articles representing 25 studies (7 middle and 18 highschool) from seven countries were included. Twelve studies measured MVPA through observational measures, seven usedaccelerometers, five used heart rate monitors and four used pedometers (including three studies using a mixof measures). Meta-analysis of 15 studies found that overall, students spent a mean (95% CI) of 40.5% (34.8–46.2%) ofPE in MVPA. Middle school students spent 48.6% (41.3–55.9%) of the lesson in MVPA (n = 5 studies) and highschool students 35.9% (28.3–43.6%) (n = 10 studies). Studies measuring MVPA using accelerometers (n = 5) showed thatstudents spent 34.7% (25.1–44.4%) of the lesson in MVPA, while 44.4% (38.3–50.5%) was found for lessons assessed viaobservation (n = 9), 43.1% (24.3–61.9%) of the lesson for a heart rate based study, and 35.9% (31.0–40.8%) for a pedometer-measured study.
Conclusions: The proportion of PE spent in MVPA (40.5%) is below the US Centre for Disease Control and Prevention andthe UK Associations for Physical Education recommendation of 50%. Findings differed according to the method of MVPAassessment. Additional strategies and intervention research are needed to build more active lesson time in PE.
Keywords: High school, Middle school, Lesson, Class, PE, Exercise, MVPA, Student, Adolescent
* Correspondence: [email protected] New England Population Health, Locked Bag 10, Wallsend, NSW2287, Australia2School of Medicine and Public Health, University of Newcastle, Callaghan2308, AustraliaFull list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Hollis et al. International Journal of Behavioral Nutritionand Physical Activity (2017) 14:52 DOI 10.1186/s12966-017-0504-0
BackgroundModerate-to-vigorous physical activity (MVPA) duringadolescence has been positively associated with a host ofphysiological and psychological outcomes such ascardiorespiratory fitness [1], reduced metabolic diseaserisk [2] and better mental health [3, 4]. The WorldHealth Organisation (WHO) recommends children andadolescents aged 5 to 17 years old participate in 60 minof MVPA everyday [5]. Internationally, as few as 20% ofadolescents meet this recommendation [6]. Schools playan important role in physical activity promotion foradolescents [7], an age that has been associated with de-clining physical activity levels [8, 9].The United States’ (US) Centre for Disease Control
(CDC) and Prevention [10] and the United Kingdoms(UK) Associations for Physical Education (AfPE) [11] ad-vise that children (5–17 years old) should participate inMVPA for 50% of PE lesson time to gain appropriatehealth and academic benefits. The most recent review toexamine the proportion of PE lesson time spent inMVPA in secondary schools (i.e., middle and highschool) was published in 2005 and reviewed 40 studies[12]. The majority of studies used heart rate monitoringto measure MVPA (n = 30), 10 studies used systematicobservation such as the System for Observing FitnessInstruction Time (SOFIT), and four used accelerometry[12]. When data from the studies were combined (not ameta-analysis), the review found that secondary schoolstudents engaged in MVPA for between 27% and 47% ofPE time depending on the type of measurement instru-ment used to measure MVPA; accelerometers-assessedMVPA was reported for 46.8 ± 13.9% of lesson time,heart rate monitor-assessed MVPA for 37.9 ± 14.6% andobservational-assessed MVPA for 26.6 ± 15.2% of lessontime [12]. Sub-analyses found MVPA levels variedaccording to the type of activity students engaged in;from almost 50% of lesson time when engaged in fitnessorientated activities (48%) or team invasion games (e.g.,basketball and soccer; 46%) compared to just one thirdof time when participating in dance and gymnastics, ornet game activities [12]. The review did not examineMVPA in middle and high school PE lessons separately.Since 2005, numerous observational and intervention
studies examining MVPA in middle and high school PElessons have been conducted. However there has beenno systematic review to examine the proportion ofsecondary school PE lesson time, without intervention,spent in MVPA. While it is important to acknowledgethat the target of 50% MVPA is only one aspect of asses-sing the quality of PE lessons, continued monitoring ofguideline implementation is important as a tool to trackany improvements in MVPA or achievements of PElesson targets. Therefore, the primary aim of thissystematic review was to update the evidence base and
determine the proportion of secondary (middle andhigh) school PE lesson time that students spend inMVPA. Secondary aims were to evaluate student partici-pation in MVPA during PE lesson time according tothree potential moderators, namely: i) school level (mid-dle or high schools); ii) type of physical activity measure-ment (accelerometer, heart rate monitoring, pedometryor observational measure); and iii) type of PE activities(fitness orientated activities, team invasion games, danceand gymnastics or net game activities).
MethodsSearch StrategyThe systematic review protocol was registered with Pros-pero on the 7th May 2014 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014009649; PROSPERO2014:CRD42014009649). The systematic reviewadhered to the Preferred Reporting Items for SystematicReviews and Meta-analysis (PRISMA) statement [13]. Atwo-step search strategy was used. Firstly, a search usingkey words was carried out across nine electronic databases:Medline, Sport Discus, CINAHL, The Central Cochranedatabase of Systematic Reviews, CENTRAL, ERIC Pro-quest, EMBASE, Scopus and PsycINFO. Key search termsand their synonyms were searched separately in four mainfilters which were then combined. Search filter one identi-fied the setting such as ‘physical education’, ‘lesson*’, ‘class*’.Search filter two referred to the target population including‘child’, ‘adolesc*’ and ‘student’. Measurement terms wereidentified using search filter three such as ‘motor activity’,‘exercise’ and ‘MVPA’. Search filter four identified the studydesign including ‘prospective studies’, ‘longitudinal studies’,‘non-randomized’. Search terms within each filter werecombined using the Boolean operator ‘or’, and all four filterswere combined to form one search using the Booleanoperator ‘and’. See Additional file 1 for a record of thesearch strategy used for each database. In the second stepof the search strategy, the reference list of the includedstudies was manually searched for additional papers notpreviously identified.The title, abstract and description/MESH heading of
the studies identified during the search were retrievedand examined by two independent reviewers (JLH andRS) to determine if the study met the inclusion criteria.The full texts of the potentially eligible studies wereretrieved and independently assessed by the two re-viewers for eligibility. If the two independent reviewersdisagreed on whether a study should be included in thereview, a third independent reviewer (EC) was consulteduntil a consensus was reached.
Inclusion and exclusion criteriaThis review considered studies i) published in Englishfrom 2005 to 2014; ii) that assessed the physical activity
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 2 of 26
levels of students during PE lessons at a secondaryschool [middle (i.e., Grade 6–8; approximately 10–14years old) or high school (i.e., Grade 7–12; approxi-mately 12–18 years old)]; iii) included a quantitativemeasure of physical activity levels (e.g., accelerometry,heart rate monitoring, pedometers or systematic obser-vational measures); iv) were of cross sectional orprospective longitudinal quantitative design, or thebaseline intervention and/or control group results ofrandomised controlled trials (RCTs), non-randomisedcontrolled trials (non-RCTs) and pre-post studies. Thecontrol group results during the study period were in-cluded if no baseline control data was provided and thecontrol group received no intervention. The reviewexcluded studies that reported on preschool or elem-entary/primary school children, abstracts, theses/dis-sertations and unpublished literature, were publishedprior to 2005, and reported on only the follow-upstudy results from interventions in RCTs, non-RCTsand pre-post studies.
Assessment of risk of biasAn 11-item tool was developed to assess the risk of biasof the included studies (Additional file 2). The tool wascreated as no existing risk of bias tool assessed bias thatwas relevant to the topic. For example, existing toolsassessed studies on participant recall bias, interviewerbias, the randomisation procedure and attrition [14–16];all criteria which were not directly relevant to thissystematic review. The existing tools lacked detailed cri-terion regarding selection and instrument bias across theschool, class and student level, which were more likelyto influence the findings. The tool consisted of sevendomains covering selection bias at the school, class andstudent level, plus selection and instrument bias relatedto the PE lessons and MVPA measures. The tool wasused by the authors in a previous systematic review ofMVPA in elementary school PE lessons [17]. In thisreview, two independent reviewers (JLH and RS) usedthe tool to assess the risk of bias of all studies includedin the systematic review. Any disagreements were re-solved through discussion between the two reviewers,and if a consensus could not be reached, a third reviewerwas consulted (EC). Each of the 11 criteria was coded as‘clearly described and present’ (yes), ‘absent’ (no), or‘unclear and/or inadequately described’ (unclear) foreach study. Each domain was considered independentlyas recommended by PRISMA [13].
Data collectionData were extracted from the retrieved papers forevidence synthesis using a pre-piloted standardised dataextraction table developed by the authors. One inde-pendent reviewer (JLH) extracted the data, and a second
independent review (RS) examined the completed dataextraction table, added any missing information, cor-rected errors and highlighted any data that were unclear.The two reviewers discussed all discrepancies. A thirdreviewer (EC) was consulted if a consensus could not bereached. Missing data were requested from study au-thors if necessary to determine study eligibility andwhere insufficient data were provided for inclusion in themeta-analysis. The extracted data included study design,the setting (region/country, middle school, high school,school level), participants (school and student sample size,student age, sex, socioeconomic status (SES), ethnicity),teacher training, aim, recruitment, response rate, meas-urement type, lesson delivery, number of lessons, lessonduration, and activities engaged in during the lesson.MVPA in PE lessons was extracted as either: i) meanpercentage of lesson time spent in MVPA, or ii) minutesof MVPA per lesson and length of the PE lesson so thatpercentage MVPA per lesson could be manually calcu-lated. The activities engaged in during the lesson/s wereextracted verbatim from the study description, with theintention to re-categorise these into four categories as inthe previous review [12]: i) fitness orientated activities, ii)team invasion games, iii) dance and gymnastics, and iv)net game activities. If lessons contained activities that fellinto more than one category, data on the time spent ineach activity from the different categories were alsoextracted (if reported).
Data synthesisData were synthesised via a narrative description of find-ings from the included studies. Summaries of the phys-ical activity levels in each study were presented as bothmean (SD/SE/95%CI) percentage of time and actual mi-nutes, if provided. Comprehensive Meta-analysis Soft-ware (version 2.2.064, July 2011) was used to pool thefindings into a meta-analysis for studies that reported i)mean percentage of time in MVPA, ii) a standard devi-ation, and iii) the number of PE lessons observed. Find-ings were combined for the main meta-analysisregardless of the assessment method. Percentage timespent in MVPA was quantified from pedometer stepsper minute by the authors (JLH and RS) using a standar-dised equation [18]. The meta-analysis was weighted byinverse variance assuming a random-effects model, ac-cording to the number of PE lessons monitored in eachstudy. A decision to assign study weighting based on PElessons was made as the factor variable of interest is thevariability of MVPA at the lesson level, not the studentlevel. As studies reported the measure at an aggregatelesson level (e.g., average of 39% of the lessons spent inMVPA) and the student sample size for each individuallesson was not clear for all studies, we are unable to as-sign study weighting by student sample size. A larger
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 3 of 26
number of PE lessons monitored in a study wouldprovide a more accurate estimate of percentage MVPAin usual PE lessons. Providing that either i) all studentsin a PE lesson are monitored, or ii) students arerandomly selected for monitoring (i.e., the protocol forobservational assessment using SOFIT), then the averagestudent percentage MVPA data collected should berepresentative of percentage MVPA in the assessedlesson regardless of the number of students monitored.Moderator analyses were performed to determine per-
cent MVPA by school level (middle or high school), typeof physical activity measurement (accelerometer, heartrate monitor, pedometer or observational measure) andtype of PE activities (fitness orientated activities, teaminvasion games, dance and gymnastics or net gameactivities). Cochran’s Q and the I2 Index tests were usedto assess statistical heterogeneity. For the I2 Index;0-40% may represent low heterogeneity; 30–60% moder-ate heterogeneity; 50–90% substantial heterogeneity; and75–100% considerable heterogeneity [14]. The moder-ator meta-analysis that examined the method of measur-ing MVPA was also used to examine methodologicalheterogeneity.
ResultsDescription of the studiesThe stages of the systematic review and study exclusionsare shown Fig. 1. The initial database search returned
8,300 journal articles prior to de-duplication, or 5,132journal articles once duplicates were removed. Followingtitle and abstract review, 71 full text articles wereretrieved and assessed for eligibility. Twenty-eightpapers representing 25 studies (7 middle school and 18high school studies) met all inclusion criteria and wereincluded in the systematic review. All study selectiondiscrepancies between the two reviewers were resolvedthrough discussion and the third reviewer was notconsulted. Missing data were requested from 13 studyauthors to determine study eligibility and/or to obtainsufficient data for the study to be pooled into the meta-analysis. Nine authors responded to the email communi-cation, of which five provided the additional requesteddata. No additional eligible articles were retrieved fromthe reference lists of the included articles.
Characteristics of included studiesThe characteristics and outcomes of the studies areshown in Tables 1 and 2. Publication dates rangedfrom 2005 [19–23] to 2014 [24, 25]. The studies wereprimarily conducted in the United States of America(USA; n = 13) and Australia (n = 6), with two studiesin Portugal and one each in the United Kingdom,Poland, Brazil and Hong Kong. All seven middleschool studies were conducted in the USA. Almost50% of the studies were of cross-sectional design (n = 12),followed by RCT’s (n = 4), non-RCT’s (n = 3), pre-post
Records identified through database searching (duplicates removed)
(n = 5132)
Additional records identified through other sources
(n = 0)
Records after duplicates removed(n =5132)
Records screened(n = 5132)
Records excluded with reasons:
Incorrect age (n = 1789)
Did not examine a PE lesson (n = 2987)
Proportion of time in MVPA not reported (or data from which proportions could be
calculated not reported) (n = 274)
Not a full-text, peer-reviewed article e.g. conference abstract or thesis (n = 11)
Full-text articles assessed for eligibility(n = 71) Full-text articles excluded, with reasons:
Incorrect age (n = 4)
Did not examine a PE lesson (n = 12)
Proportion of time in MVPA not reported (or data from which proportions could be
calculated not reported) (n = 26)
Not a full-text, peer-reviewed article e.g. conference abstract or thesis (n = 1)
Full-text articles included in qualitative synthesis
(n = 28)*representing 25 studies
Studies included in quantitative synthesis (meta-
analysis)(n = 15)
Scr
een
ing
Incl
ud
edE
ligib
ility
Iden
tifi
cati
on
Fig. 1 PRISMA flow chart illustrating study inclusions through the stages of the systematic review and meta-analysis
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 4 of 26
Table
1Metho
dologicalcharacteristicsof
second
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
Reference:first
author,year&
stud
ytype
Samplesize,
scho
ols(n),
stud
ents(n)
Popu
latio
nage
(mean(SD)or
rang
e),
sex(%
female),SES,
ethn
icity,g
eographic
locatio
n
Aim
,study
grou
psinclud
edin
analysis
Recruitm
ent
metho
d,respon
serate
(%)
Outcome
measures
Measure
ofMVPA
PElesson
delivery,
season
/mon
th&
year
Num
berof
PEclassesob
served
,minutes
PEactivities
MiddleScho
ols
Barrosoet
al.
2009
[36]
Cross-sectio
nal
stud
y
Scho
ols:17
middlescho
ols
Stud
ents:6
th–
8thgrade,
numbe
rof
stud
entsNR
Age
,sex,ethnicity,
SESNR
Texas-Mexicobo
rder,
USA
Toassess
awaren
ess/adhe
rence
toSenate
Bill42,&
toassess
theim
pact
ofSenate
Bill42
onthefre
quen
cy/qualityof
structured
PA,&
prevalen
ceof
child
self-repo
rted
PAbe
hav-
iours&child
overweigh
talon
gtheTexas-Mexican
border
a
Group
A=subsam
pleof
17scho
olson
Texas-Mexico
border
Asubsam
ple
(17/112)
of2004/05SPAN
middlescho
ols
in4Texas-
Mexicobo
rder
metro
areas
(based
onprob
-ability
sampling).
Respon
serate:
NR
Awaren
essof
&adhe
renceto
Senate
Bill42,
self-repo
rtPA
&SSR,PE
class
attend
ance,
MPA
,VPA
,he
ight,w
eigh
t,BM
I,be
hav-
ioural
characteristics
SOFIT
PEinstructors,
Female&Male
Sprin
g2007/08
≤3PE
lesson
sob
served
per
scho
ol(1
observationpe
r6th,7
th&8th
grade);classes
couldbe
mixed
;total=
46
NR(m
ainly
indo
oractivities)
Coe
etal.2006.
[32]
RCT
Scho
ol:1
publicscho
olStud
ent:214
6thgrade
stud
ents
11.5±0.4years
(rang
e10–12.8years);
51%
boys,49%
girls;
68%
White,10–14%
Hispanic,3–4%
Black,
3-6%
Asian,12%
othe
rethn
icity.SES
NR
Western
Michigan,
USA
Tode
term
inetheeffect
ofPE
classen
rolm
ent&ph
ysical
activity
onacadem
icachievem
entin
middlescho
olchildren
Group
A=allP
Elesson
s(no
control)
Recruitm
ent:
stud
ents
recruitedwith
inscho
ol,con
sent
form
ssent
toparentson
first
dayof
scho
olRespon
serate=
36.8%
stud
ents
(229/622).93.4%
(214/229)
completed
data
collection
Acade
mic
achievem
ent,
%MPA
&%VPA
inPE
lesson
,habitualPA
/day,he
ight,
weigh
t,BM
I
SOFIT
2PE
teache
rsin
thescho
ol8lesson
sob
served
(each
teache
r(2)
observed
4tim
esthroug
hout
the
year),55
min
classes/day
NR
Fuet
al.2013
[27]
Non
-rand
omised
trial
Scho
ol:1
urbanmiddle
scho
ol,7
th–8
th
grade
Stud
ents:61
stud
ents
12.6(0.6)years;41%
male.Ethn
icity
&SES
NR
Mou
ntainWest
region
,USA
Toexam
inetheeffectsof
ahe
alth-related
physicalfitne
ss-
basedbasketballprog
ram
onmiddlescho
olstud
ents’in-class
physicalactivity,p
erceived
compe
tence,&en
joym
entas
comparedto
theeffectson
thosestud
yvariables
show
nby
acontrolg
roup
participatingin
thetradition
alapproach
basket-
ballun
itGroup
A=baselineresults
ofHealth
relatedph
ysicalfitne
ssbasketballun
it;Group
B=
Baselineresults
ofTradition
alapproach
basketballun
it
Recruitm
ent:
stud
ents
recruitedwith
inscho
ol,p
aren
ts/
guardians
provided
inform
edwritten
consen
tRespon
serate:
NR
In-class
PA,
perceived
compe
tence,
children’s
enjoym
ent
Pedo
meter
PEteache
r,master’s
degree
inPE,30min
training
onstud
yprotocol
(ratio
nale,hands
onexpe
rienceof
implem
entin
gstrategies)
1×50
min
PEsessionclass/
weekfor
6weeks
(only
baselinedata
includ
edin
this
analysis)
Basketball.
Includ
edaerobic
&static/dynam
icwarm-up
(5min),skillre-
lateddrills
(15min),game-
play
(30min)
Gao
etal.2011
[37]
Cross-
sectionalStudy
Scho
ol:1
subu
rban
12.48(1.02)
years;
50%
male;19.81kg/
m2 ;22%
overweigh
t/
Toiden
tifythepe
rcen
tage
sof
stud
entsareoverweigh
t&
obesebasedon
BMI;stud
ents’
Recruitm
ent:
recruitedwith
inscho
ol,
BMI,MVPAin
PEclass
Accelerom
eter
3PE
lesson
s,Taug
htby
PEteache
rs,
2or
3×90
min
PEclasses/week
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 5 of 26
Table
1Metho
dologicalcharacteristicsof
second
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
(Con
tinued)
publicscho
ol,
6-8thgrade
Stud
ents:149
stud
ents,10–
14yearsold
obese;89.3%
Caucasian,7.4%
AfricanAmerican,2%
Asian
American,1.3%
HispanicAmerican;
mostly
middleto
high
SESfamilies;
28.9%
from
6thgrade,
36.2%
from
7thgrade,
34.9%
from
8thgrade
Southe
rnUSA
PAlevelsin
PEas
measuredby
accelerometers;to
determ
ineif
therearesign
ificant
differences
instud
ents’PAlevelsacross
different
BMIg
roup
s(health
yweigh
tvs
overweigh
t/ob
ese)
Group
A=allP
Elesson
s(total);
then
results
byweigh
tstatus
(health
yweigh
t&overweigh
t/ob
ese)
perm
ission
obtained
from
participants&
parents/
guardians
Respon
serate:
NR
teaching
onalternatedays
Catch-ball,
walking
/jogg
ing,
line
dancing,
soccer,table
tenn
is.PEtim
einclud
edwarm-uprou-
tines,activities
&games.A
llclassesen
ded
with
alesson
assessmen
t
Liuet
al.2013
[34]
Non
-rand
omised
trial
Scho
ols:tw
omiddlescho
ols,
6thgrade
Stud
ent:247
stud
ents;
PE4Life
=154
(80bo
ys,74
girls),
Tradition
al=93
(37bo
ys,56
girls)
11.58±0.61
&11.40
±0.46
years(m
ean
ageof
2grou
ps);
47.4%
male;med
ian
incomeof
grou
ps~$30,000;>95%
white
ethn
icity
Region
NR,USA
Tocompare
health-related
physicalfitne
ssof
2samples
of6thgradestud
enten
rolledin
2different
PEprog
rams(PE4life
Prog
ram
&atradition
alPE
pro-
gram
),which
werein
striking
contrastin
theirMVPAlevelsin
PEclass
Group
A=tradition
alPE
prog
ram
Recruitm
ent:all
6thgradersfro
m2scho
olsinvited
toparticipate
Respon
serate:
NR
MVPAin
PElesson
s,%
body
fat,BM
I,prog
ressive
aerobic
cardiovascular
endu
rancerun,
fitne
sstest
SOFIT
PEspecialists,
9yearsof
expe
rience,aged
36–52yearsold
43lesson
sob
served
ateach
scho
ol,
90min
PE/w
eek
PE4life
Prog
ram:
Individu
al/
lifetim
esports&
streng
th/fitn
ess
activities
Tradition
alPE
prog
ram:
compe
titive
team
sports&
othe
rPA
McKen
zieet
al.
2006
[29]
RCT
Scho
ols:36
publicscho
ols,
6field
sites
Stud
ents:m
ean
(SD)1027
(285)
stud
ents/
scho
ol
100%
girls;47%
non-
white.34%
received
freeor
low
cost
meals.A
ge&SESNR.
Multi-site,U
SA
Toassess
girls’PAin
middle
scho
olPE
asitrelatedto
field
site,lessoncontext&locatio
n,teache
rge
nder,&
class
compo
sitio
nGroup
A=baselinevaluefro
mtheTA
AGstud
yscho
ols
Recruitm
ent:
Scho
ols
participatingin
TAAG
Respon
serate:
NR
MVPAin
PElesson
s,lesson
context,activity
prom
otion
SOFIT
60%
taug
htby
femalePE
teache
rsJan-May
2003
431lesson
s(70–
74pe
rsite).
Meanlesson
leng
th37.3±
9.4min.30
stud
ents/class
83%
inco-
educationalfor-
mat.O
bserva-
tions
occurred
over
3days/
scho
ol
NR
65%
held
indo
ors
Sprin
geret
al.
2013
[38]
Scho
ol:30
publicmiddle
Who
lesample(6th-
8thgrade)
The3.5year
CATC
HMiddle
Scho
olProjectaimed
toRecruitm
ent:30/
32eligiblepu
blic
BMI,7-dayPA
,sede
ntary
SOFIT
PEteache
rs84
observations
from
21scho
ols,
NR
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 6 of 26
Table
1Metho
dologicalcharacteristicsof
second
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
(Con
tinued)
Group
rand
omized
SerialC
ross-
sectionalStudy
scho
ols,6th-8
th
grade(M
VPA
collected
insubsam
pleof
21scho
ols)
Stud
ents:N
R,on
ly6th-7th
gradestud
ents
provided
data
onMVPAin
PElesson
s
demog
raph
ics-
13.9years;51.2%
female;37.9%
overweigh
t&19.2%
obese;51.9%
Hispanic,25.1%
White,13.2%
African
American;58.7%
econ
omically
disadvantage
dTexas,USA
prom
otePA
,health
yeatin
g,&
obesity
preven
tionam
ongyear
6–8middlescho
olstud
ents&
theirfamilies.The
evaluatio
naimed
toob
servechange
sin
energy
balancebe
haviou
rsbasedon
expo
sure
toCATC
Hover
3.5years
Group
A=baselinedata
from
asubsam
pleof
21scho
ols
scho
olsselected
from
5central
Texas
inde
pend
ent
scho
oldistricts.
Stud
ents
recruited
throug
hverbal&
writteninvitatio
nin
core
classes.
Stud
entassent
&parent
passive/
activeconsen
t.Respon
serate:
100%
(30/30)
scho
olsagreed
toparticipate,
72%
stud
ents
(2,841/3,944)
participated
atbaseline
behaviou
r,MVPAin
PEles-
sons,d
ietary
behaviou
rs,re-
latedpsycho
-socialcon-
structsinclud
-ingsocial
supp
ort,ho
me
availability&
accessibility
offru
it&
vege
tables
4rand
omly
selected
PEclasses(2
×6th
grade&2×7th
gradeclasses)
HighScho
ols
Bron
ikow
skiet
al.2005[23]
Non
-rand
omised
trial
Scho
ol:1
junior
scho
olStud
ents:N
R,4
children
measuredpe
rPE
class
13years.Sex,
ethn
icity
&SESNR
Poznan,Poland
Toanalyse&presen
tdifferences
betw
eenthe2
Polishsystem
sof
physical
education(3
PEclasses/week&
4PE
classes/week)
Group
A=3PE
classes/week;
Group
B=4PE
classes/week
Recruitm
ent:
stud
ents
recruitedwith
inscho
ol,p
aren
tsprovided
inform
edconsen
tRespon
serate:
NR
Health
related
fitne
ss(volum
e&intensity
ofPA
inPE
classes)
HR
mon
itorin
gTw
oPE
class
sche
dulesof
3&4
lesson
sof
PEpe
rweek,45
min
each
2002–04
Firsthalfof
2002/034PE
classespe
rweek
(71classes)
Second
halfof
2003/043PE
classespe
rweek
(78classes);
separate
classes
forbo
ys&girls
Athletics,
basketball,
volleyball,
gymnastics,
gymnastics
jumps,table
tenn
is,m
otor
fitne
sstests,
aerobic,football,
othe
rteam
sports(e.g.,floor
ball&softball)
Cho
wet
al.
2009
[45]
Cross-sectio
nal
Stud
y
Scho
ols:30
scho
ols(6%
ofthecoun
tries
co-edu
catio
nal
scho
ol,10%
ofbo
yson
ly&
10%
ofgirls
onlyscho
ols)
Stud
ents:N
R.Class
size
5–55,
mean32.8
(9.01)
63classesin
7th
grade
49classesin
8th
grade
62classesin
9th
grade
42classesin
10th
grade
6classesin
11th
grade
16classesin
12th
grade
Class
size
=32.8(9.01)
stud
ents.A
ge,Sex,
SESðn
icity
NR
Tomeasure
stud
entph
ysical
activity,lessoncontext,&
teache
rbe
haviou
rdu
ring
physicaled
ucationlesson
sin
arepresen
tativesampleof
second
aryscho
olsin
Hon
gKo
ng,&
assess
theinfluen
ceof
classge
nder
compo
sitio
n&
othe
ren
vironm
entalfactors
(e.g.,lesson
locatio
n,activity
areassize,class
size)o
nstud
ents’p
hysicalactivity
levels
durin
gthoselesson
sGroup
A=allP
Elesson
s(no
interven
tion)
Recruitm
ent:NR
Respon
serate:
NR
Stud
entPA
,lesson
context,
teache
rbe
haviou
r
SOFIT
65PE
specialists
(38men
,27
wom
en),mean
(SD)age34.4(8.5)
yearsold,
teaching
expe
rience12
(8.4)years
Decem
ber2005-
May
2006
238ob
servations
each
from
123
classes(m
ean
time57.1min,
rang
e19–100),
rand
omly
selected
days
Team
activities/
sports
(basketball,
soccer,volleyball,
team
hand
ball,
rugb
y)individu
alactivities/spo
rts
(gym
nastics,
badm
inton),
expressive
activities
(dance,
rope
skipping
),othe
rconten
t(fitnesstraining
,ph
ysicalfitne
ss),
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 7 of 26
Table
1Metho
dologicalcharacteristicsof
second
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
(Con
tinued)
Hon
gKo
ngIsland
,Ko
wloon
,New
Territo
ries,Hon
gKo
ng
freeplay
activities
Con
leyet
al.
2011
[26]
Pre-
postinterven
-tio
ntrail
Scho
ol:2
co-
educational
Year
7PE
classes
Stud
ents:37
participants
12.6±0.4years;
40.5%
males.SES
ðn
icity
NR
Victoria,A
ustralia
Toexplorewhe
ther
children
caniden
tifytim
espen
tin
MVPA,&
investigatewhe
ther
heartrate
biofeedb
ackwou
ldim
provechildren’sability
toestim
atetim
espen
tin
MVPA
Group
A=results
from
1pre-interven
tionlesson
Recruitm
ent:
stud
ents
recruitedwith
inscho
ol,children
&theirlegal
guardians
provided
written
inform
edconsen
tRespon
serate:
NR
Heartrate
measured
minutes
MVPA,
height
weigh
t,self-estim
ated
timein
MVPA
HR
mon
itorin
gPE
teache
rs,
respon
siblefor
lesson
planning
&de
livery,lesson
&teaching
variatio
ncontrolledby
combing
2PE
classesforthe
stud
yTerm
II(Apr-Jun
)du
ringscho
ols
recreatio
nalfitn
ess
PEun
it
1×70-min
pre-
interven
tionPE
lesson
(~55
min
practicalPE)in-
clud
edin
this
analysis;
Overall8PE
lesson
smon
itoredover
7weeks
(3lesson
sche
duled
per2weeks)
Circuitlesson
:10
min
warm
upgame,circuit
activity
stations
(runn
ing,
jumping
,ho
pping,
step
ping
)
Dud
leyet
al.
2012a[39]
&Dud
leyet
al.
2012b[40]
Baselinecross-
sectional
stud
y/Long
itu-
dinalstudy
Scho
ol:6
scho
ols(2
co-
educational,2
boys-only,2
girls-only),Year
7PE
classesat
baseline,Year
8PE
classesat
1year
follow-
up Stud
ent:NR,4
childrenpe
rclass(n=81
lesson
sat
baseline;51
atfollow-up)
ran-
domlyselected
tobe
observed
12.8(0.5)years;55%
girls;38%
spoke
Englishas
main
lang
uage
atho
me;
60%
reside
din
subu
rbsin
the5
decilesof
greatest
socioe
cono
mic
disadvantage
.Ethn
icity
NR
South-WestSydn
ey,
NSW
,Australia
Dudleyet
al.2012a
-To
determ
inethelevelsof
PA,
lesson
context&teache
rinteractionstud
entsreceive
durin
gPE
insecond
aryscho
ols
inNSW
,Australia
Dudleyet
al.2012b
-To
exam
inethepe
rcen
tage
ofclasstim
espen
tparticipatingin
PA,lessoncontext&teache
rinteractiondu
ringsecond
ary
scho
olPE
&ho
wthose
variables
change
dover
time
from
Year
7to
Year
8Group
A=baselineYear
7results;G
roup
B=follow-up
Year
8results
Recruitm
ent:
Collected
from
PALD
Cproject.
Scho
oliden
tified
byNSW
Dep
artm
entof
Education&
Com
mun
ities
(high&
lingu
istically
diverse
backgrou
nds).A
lliden
tified
scho
ols/Year
7stud
entsinvited
toparticipate
(follow-upin
Year
8)Respon
serate:
>99%,
658stud
ents
consen
tedto
demog
raph
icdata
taken;504
(77%
)atfollow-
up
PAlevels,
lesson
instruction
conten
t,scho
oltype
SOFIT
AllPE
teache
rsat
the6scho
ols,PE
teache
rsgiven
<1weekno
ticed
ofPE
lesson
tobe
mon
itored,
mean
of24
stud
ents/
class
BaselineJul-D
ec2008;Follow-up
Jul-D
ec2009
81PE
lesson
smon
itoredat
baselineover
5mon
ths(3
rand
omly
selected
PElesson
son
3separate
days
for
each
classat
each
scho
ol),51
PElesson
smon
itoredat
follow-up
NR
Faircloug
het
al.2005[12,
19]&
Faircloug
het
al.2006[20]
bQuasi-
expe
rimen
tal
RCT
Scho
ol:1
c-ed
ucational
high
scho
ols,2
Year
7girls
PEclasses(30stu-
dentseach)
~12.4±0.3years;
100%
girls.ethnicity
&SESNR
Merseyside(North-
WestEngland),
England
Faircloughet
al.2005-To
exam
inewhe
ther
ateaching
interven
tioncoulden
hance
girls’p
hysicaledu
catio
nlevels.
Toassess
whe
ther
the
interven
tioncomprom
ised
the
attainmen
tof
planne
dlesson
Recruitm
ent:
stud
ents
recruitedwith
inscho
ol,informed
writtenconsen
tprovided
Anthrop
ometric,
PAlevelsin
PE,
psycho
logical
characteristics
(intrinsic
motivation&
perceived
SOFIT&HR
mon
itorin
g1male&1
femalespecialist
physical
education
teache
rs,>
4yearsteaching
expe
rience,
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 8 of 26
Table
1Metho
dologicalcharacteristicsof
second
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
(Con
tinued)
Stud
ents:33
girls
consen
ted
(11–12
years
old),d
ata
analysed
on26
girls,
4girls/class
mon
itored
with
SOFIT
objectives,&
levelsof
intrinsic
motivation&pe
rceived
compe
tence
Faircloughet
al.2006-To
increase
cardio
respiratory
health-enh
ancing
physicalactiv-
itylevelsdu
ringgirls’g
ymnas-
ticslesson
sby
manipulating
thelesson
contexts&teache
rbe
haviou
rs,&
toachievethis
with
outcomprom
isingothe
rplanne
dlesson
objectives
Group
A=baselineinterven
tion
data;G
roup
B=baselinecontrol
data
Respon
serate:
55%
ofstud
ents
(33/60)
compe
tence),
teache
revaluatio
ns
teache
rstook
usualclass
1×2hpe
riod/
week,classes
taug
htin
mixed
-ability,
sing
lesex
grou
ps(30–32
stud
entspe
rclass).A
ctual
lesson
leng
th82.4min
(con
-trol)&76.0min
(interven
tion).
6un
itlesson
observed
inthe
interven
tion&
controlg
roup
s.Only1baseline
lesson
for
interven
tion&
controlg
roup
sinclud
edin
this
analysis
Gym
nastic
lesson
s
Ferriera
etal.
2014
[24]
Cross-sectio
nal
stud
y
Scho
ols:3
Portug
uese
publicscho
ols
Stud
ent:191
stud
ents(12–
17yearsold)
14.55±1.79
years;
51%
male.SES&
ethn
icity
NR
Castelo
Branco
district,Po
rtug
al
Tode
term
inetheam
ount
ofMVPAun
dertaken
durin
gaPE
classby
usingan
accelerometer,&
toverifyifthe
recorded
values
arein
linewith
therecommen
dedgu
idelines
Group
A=allP
Elesson
s(no
interven
tion)
Recruitm
ent:
stud
ents
recruitedwith
inscho
ol,informed
writtenconsen
tprovided
byparent/guardian
&thescho
oldirector
Respon
serate:
NR
PEclassMVPA
accordingto
age&ge
nder
Accelerom
eter
Specialised
physicalactivity
educator
2007/08
1×90
min
PEclass/week
exam
ined
for
each
scho
ol,6
×10
min
exercises
+30
min
instruction/
organisatio
n&
bathing/
changing
clothe
s
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 9 of 26
Table
1Metho
dologicalcharacteristicsof
second
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
(Con
tinued)
Team
ball
sports(fo
otball,
hand
ball&
basketball),
held
inou
tdoo
rspace
Hanno
net
al.
2005
[21]
Pre-
postcrossover
trial
Scho
ol:1
Coe
ducatio
nal
middlescho
ol,
2PE
classes,
9th&10
th
grade
Stud
ent:78
stud
ents
47%
male;
pred
ominately
Caucasian
&middle
class;ageNR
North
Florida,USA
Tocompare
activity
levels,as
measuredby
pedo
meter
step
coun
tspe
rminute,of
high
scho
olmales
&females
participatingin
coed
ucational&
sing
lege
nder
flagfootball
gameplay,&
investigatehigh
scho
olgirls’viewsof
participationin
co-edu
catio
nal
&sing
lege
nder
flagfootball
play
Group
A=coed
ucational
lesson
;Group
B=sing
lege
nder
lesson
Recruitm
ent:
stud
ents
recruitedwith
inscho
ol,p
aren
tsprovided
inform
edwritten
consen
tRespon
serate:
100%
PAin
PEclass
Pedo
meter
2PE
teache
rs.1
×malewith
8years
ofexpe
rience,1×
femalewith
14yearsof
expe
rience
~45
min
classes,
Sing
lege
nder
&coed
ucational
classes
Flag
play
(incl.
warm
upexercises,10
min
skilldrills,20–
25min
game).
Pedo
meter
only
wornfor20
min
game
How
etal.
2013
[33]
RCT
Scho
ol:1
inde
pend
ent
scho
ol,8
×Year
8PE
classes(4
male
classes,4
femaleclasses)
Stud
ents:257
12.91(0.29)
years.
Sex,ethn
icity
&SES
NR
Western
Australia,
Australia
Toexam
inewhe
ther
stud
ents
with
inan
interven
tiongrou
p,who
wereprovided
with
choice
with
inPE,rep
orted
greaterautono
mou
smotivation,morefavourable
percep
tions
ofautono
my
supp
ort,&displayedhigh
erin-
classPA
levelthanthosewith
inacontrolcon
ditio
nGroup
A=Regu
larPE
control
grou
p
Recruitm
ent:
letter
sent
toparentswith
passiveconsen
tform
towith
draw
consen
t.Stud
ents
provided
consen
tbe
fore
thestud
ybe
gan
Respon
serate:
NR
PAlevels,PE
motivation,
autono
my
supp
ortive
lesson
s
Accelerom
eter
4PE
teache
rs,
attend
ed40
min
briefingbe
fore
stud
y
60min
PEtim
eallocated,
~40
min
PAfor
each
lesson
Netball,tenn
is&tee-ball
Krem
eret
al.
2012
[41]
Cross-sectio
nal
stud
y
Scho
ols:8
second
ary
scho
ols(16
scho
olstotal)
Stud
ents:84
second
ary
scho
olstud
ents(272
stud
entstotal),
4stud
ents
from
each
class
(2male,2
female)
rand
omly
Dem
ograph
icsfro
mprim
ary&second
ary
scho
ols-14.3(2.8)
years;50.2%
female;
72.6%
white
skin
colour.SES
NR
City
ofPelotas,
Southe
rnBrazil
(Sou
thof
thestate
RioGrand
edo
Sul)
Toevaluate
theintensity
&du
ratio
nof
physicaleffortsin
PEclassesin
prim
ary&
second
aryscho
olGroup
A=1stsecond
aryscho
ol;
Group
B=2n
dsecond
ary
scho
ol;G
roup
C=3rdsecond
ary
scho
ol
Recruitm
ent:list
ofcity’sscho
olob
tained
,11
prim
ary&8
second
ary
scho
olsdraw
n,stratifiedby
teaching
netw
ork(3
prim
ary&
second
ary
scho
ols
coincide
d)
BMI,MVPAin
PElesson
sAccelerom
eter
NR
MeasuredAug
-Dec
2009
218classestotal,
numbe
rof
second
ary
scho
ollesson
sob
served
NR
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 10 of 26
Table
1Metho
dologicalcharacteristicsof
second
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
(Con
tinued)
selected
tobe
observed
durin
g3
classes
Respon
serate:
100%
ofscho
ols.
Stud
ents
respon
serate
NR
NR
Lonsdaleet
al.
2013
[28,54]&
Rosenkranz
etal.2012[30]
Cluster
RCT
Scho
ols:5
scho
ols(2
inde
pend
ent
&3Catho
licscho
ols),8
th
grade,3
scho
ols
provided
4classes,2
scho
ols
provided
2classes
Stud
ents:288
total
13.6years;50.4%
male.SESðn
icity
NR
Sydn
ey,A
ustralia
Toexam
inetheeffectsof
3SD
T-basedmotivational
strategies
onPA
&sede
ntary
behaviou
r,as
wellastheir
hypo
thesized
antecede
nts
durin
gPE
lesson
sGroup
A=baselinedata
for
control/u
sualpractice;Group
B=baselinedata
forinterven
tion
‘relevance’;G
roup
sC=baseline
data
forinterven
tion‘providing
choice’;Group
D=baseline
data
forinterven
tion‘free
choice’
Recruitm
ent:20
scho
olsincited
tojoin
(9de
clined
dueto
timeconstraints,
5didn
’trespon
d,1was
unableto
participatedu
eto
PEteache
rinjury).All
principals,PE
teache
rs&
parentsprovided
writtenconsen
tRespon
serate:
80.67%
completed
baseline
assessmen
t,85.01%
completed
follow-up(245/
288)
PA,M
VPA,&
stud
ent
motivation
durin
gPE
class,
sede
ntary
behaviou
r,pe
rcep
tions
ofteache
rsupp
ort,
psycho
logical
need
ssatisfactions
Accelerom
eter
16PE
teache
rsOct-Dec
2013
Differing
duratio
nof
PElesson
,PAdata
collected
infirst
20min
oflesson
Dance,netball,
touchrugb
y
Owen
etal.
2013
[44]
Cross-sectio
nal
stud
y
Scho
ol:1
inde
pend
ent
Catho
licbo
ysscho
ol,Year9
stud
ents
Stud
ents:131
participants,
completedata
in61
stud
ents
14.36(0.48)
years;
100%
male.SES&
ethn
icity
NR
Sydn
ey,A
ustralia
Toinvestigateho
wmuchof
theob
served
variatio
nin
adolescent
boys
MVPAlevels
(duringPE
&leisuretim
e)was
explaine
dby
individu
al-&
class-levelm
otivation
Group
A=allP
Elesson
s(no
interven
tion)
Recruitm
ent:
stud
ents
recruitedwith
inscho
ol,p
aren
tsprovided
inform
edwritten
consen
tRespon
serate:
131/180
stud
ents
enrolled(72.8%
),61/131
stud
ents
provided
completedata
(46.6%
)
MVPAin
PElesson
s,motivation
towards
PEin
lesson
s,motivation
towards
PAin
leisuretim
e
Accelerom
eter
NR
NR
NR
Sand
erset
al.
2014
[25]
Scho
ol:1
Catho
licbo
ys14.36(0.48)
years;
22.36kg/m
2 ;100%
Tocompare
i)adolescent
boys’PAbo
utleng
thin
2PA
Recruitm
ent:
stud
ents
MVPA,VPA
,MPA
,LPA
&Accelerom
eter
Regu
larscho
olPE
teache
r
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 11 of 26
Table
1Metho
dologicalcharacteristicsof
second
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
(Con
tinued)
Cross-sectio
nal
stud
yscho
ols,6PE
classes,Year
9Stud
ents:133
stud
ents,
analysison
74stud
ents
male.SESðn
icity
NR
Sydn
ey,A
ustralia
contexts;leisure
time&PE
lesson
s,&ii)theeffect
ofvaryingaccelerometer
epoch
leng
thon
estim
ates
ofMVPA,
VPA,M
PA,LPA
&sede
ntary
behaviou
rin
both
contexts
Group
A=allP
Elesson
s(no
interven
tion)
recruitedwith
inscho
ol,stude
nts
provided
voluntarywritten
assent
Respon
serate:
74%
ofparticipants
consen
ted(133/
180),analysison
74/133
(56%
)
sede
ntary
behaviou
rdu
ringPE
lesson
s&
leisuretim
e
12PE
lesson
s(2
lesson
spe
rclass
×6classes)
Soccer
Scrugg
set
al.
2010a[46]
Cross-sectio
nal
stud
y
Scho
ol:3
high
scho
ols
Stud
ents:189
stud
ents
16.74(0.99)
years;
43.9%
male;169.11
±9.10
cm;67.08
±13.02kg/m
2 ;8.65%
obese;16.76%
overweigh
t.SES&
ethn
icity
NR
Upp
ermid-w
estern
USA
Tocompare
therelative&
absolute
agreem
entbe
tween
W4L
DUO&Yamax
SW651
pedo
meterson
themeasure
ofstep
s/min
&theW4L
DUO&
observed
PAtim
e(m
in)inhigh
scho
olPE
Group
A=YA
MAXSW
651
Pedo
meter
used
tomeasured
MVPA;G
roup
B=W4L
DUO
pedo
meter
used
tomeasure
MVPA;G
roup
C=SO
FITused
tomeasure
MVPA
Recruitm
ent:
with
inthe
scho
ols
(<18
year
old
stud
ents
provided
parentalconsen
t,>18
year
old
stud
ents
provided
person
alconsen
t)Respon
serate:
NR
Step
s/min,
physicalactivity
time
Pedo
meter
&SO
FIT
3certified
PEpractitione
rsrepresen
ting
urban,subu
rban
&ruralcom
mun
ities
12PE
classes
collected
durin
g16
lesson
s.Bo
thpe
dometer
measures&
SOFITrecorded
onthesame
lesson
.Tradition
al50
min
sche
duledlesson
(36.72
(4.42)
min);Block
90min
sche
duledlesson
(76.19
(4.17)
min)
NR
Scrugg
set
al.
2010b[47]
Cross-sectio
nal
stud
y
Scho
ols:6high
scho
ols(5
public,1
private),27PE
classes,9th-12th
grade
Stud
ents:218
stud
ents(16
stud
ents/class
worea
pedo
meter)
16.52(1.08)
years;
169.61
(9.23)
cm;
67.44(12.69)kg;
23.41(3.99)
kg/m
2 ;49.5%
male;15%
non-Caucasian.SES
NR
Upp
ermid-w
estern
USA
Toqu
antifytherecommen
ded
minim
umlevel(i.e.,50%
ofthe
classtim
e)of
MVPAwith
inhigh
scho
olPE
viape
dometry/m
in,
andto
exploretheinfluen
ceof
lesson
duratio
n(i.e.,traditio
nal
v’sblocksche
dules)on
quantifying
MVPAviastep
s/min
Group
A=allP
Elesson
s(no
interven
tion)
Recruitm
ent:
with
inthe
scho
ols
(<18
year
old
stud
ents
provided
parentalconsen
t,>18
year
old
stud
ents
provided
person
alconsen
t)Respon
serate:
NR
Step
s/min,%
timeen
gage
din
MVPA,tim
een
gage
din
MVPA
Pedo
meter
10certified
physicaled
ucators
27PE
classes
(traditio
nalclass
45–50min;b
lock
class90
min),40
PElesson
s(30
tradition
al;10
block).
Tradition
allesson
36.88
(4.07)
min;b
lock
lesson
78.56
(5.08)
min
Blocklesson
s:dance,invasion
game&fitne
sscourse
them
es.
Tradition
allesson
s:Fielding
,invasion
&ne
twallg
ames,
dance/
gymnastics,
fitne
sscourse,
rope
s/team
buildingthem
es
Surapibo
onchai
etal.2012[43]
Cross-sectio
nal
stud
y(valid-
ationstud
y)
Scho
ol:6
scho
ols,grades
3,5,6,7,8,9,10
(onlygrade6–
10exam
ined
inthisreview
)
Grade
6:12.33
(1.16)
years,20.0
(5.66)
kg/m
2
Grade
7:12.00
(0.01)
years,34.67
(4.51)
kg/m
2
Tode
velop,
validate&testthe
reliabilityof
theSimpleActivity
Measuremen
t(SAM)instrumen
tforassessingstud
entMVPA
durin
gscho
olPE
classesrelated
tothepo
tentialfor
evaluatin
g
Recruitm
ent:
parent
orstud
entconsen
tno
trequ
iredas
thisarea
was
requ
iredas
a
MVPAin
PElesson
sSA
MTool
(observatio
nal
tool)
PEteache
rslate
fall2009
6PE
classes
observed
with
SAM
tool;45–
50min
lesson
s(17–62
stud
ents
perclass)
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 12 of 26
Table
1Metho
dologicalcharacteristicsof
second
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
(Con
tinued)
Stud
ents:281
stud
entstotal
(allgrades);HR
=36
(24
stud
entsfro
mmiddle&high
scho
ol);SA
M=
281(high&
middlescho
olstud
entsNR)
Grade
8:13.86(0.90)
years,24.40
(4.04)
kg/m
2
Grade
9:14.13(0.35)
years,35.17
(7.89)
kg/m
2
Grade
10:15.00
(0.01)
years,40.50
(3.25)
kg/m
2
Who
lestud
ent
sample
demog
raph
ics-50%
male;92%
econ
omically
disadvantage
d’89.5%
Hispanic,7.4%
African
American,2.7%
White
SanAnton
io,Texas,
USA
theachievem
entof≥50%
ofPE
classtim
espen
tin
MVPA
Group
A=allP
Elesson
s(no
interven
tion)
partof
gene
ral
PEcurriculum
.Respon
serate:
NR
Variety
ofPE
units
includ
ing
basketball,
hand
ball&
fitne
sscond
ition
ing
Vido
niet
al.
2012
[31]
Sing
lesubject
multi-elem
ent
stud
y
Scho
ol:1
Kind
ergarten
–year
12pu
blic
scho
ol,8
th
gradeon
lyassessed
,1PE
class
Stud
ents:18
stud
ents
13-14yearsold;
55.6%
male;middle
classSES.Ethn
icity
NR
Midwestern,U
SA
Toinvestigatetheeffectsof
agrou
pde
pend
entcontinge
ncy
strategy
calledFairPlay
Gam
eon
stud
ents’heartratesin
PElesson
sGroup
A=Baselineresults
only
(4days
oflesson
s)
Recruitm
ent:
with
inscho
ol,
parental,teacher
&stud
ent
consen
tob
tained
Respon
serate:
NR
MVPAin
PElesson
s,he
art
rate,social
validity
HR
mon
itorin
gMalePE
teache
r,20
yearsteaching
expe
rience,
14yearsteaching
&coaching
basketballat
stud
yscho
ol
Everylesson
for
15days,35min
lesson
(5min
warm-up,
15min
practice
drills,12
min
game,3min
closure)
Onlybaseline
(4days
oflesson
s)results
includ
ed
Basketball
Wanget
al.
2005
[22]
Cross-sectio
nal
stud
y
Scho
ol:1
scho
ol,7
th
grade,co-
educationalP
Eclasses
Stud
ents:28
stud
ents
12.5years(boys)&
12.1years(girls);50%
male;1.51–17.6cm
;40–80kg;17.1–
28.9kg/m
2 .SES&
ethn
icity
NR
NorthernPo
rtug
al
Touseane
whe
artrate
mon
itorto
investigate
Portug
uese
7thgradestud
ents’
PAlevelsdu
ringthedifferent
indo
orPE
classes
Group
A=90
min
lesson
;Group
B=45
min
lesson
Recruitm
ent:
Scho
olrecruitm
entNR.
Stud
ents
rand
omly
selected
from
atotalsam
pleof
264stud
ents
Respon
serate:
NR
PAlevels
durin
gindo
orPE
classes
HR
mon
itorin
gPE
educators,25–
45yearsold
14indo
orPE
classes(7
×45
min
&7×
90min
classes)
Football,
basketball,
hand
ball,
volleyball,
gymnastics,&
skillevaluatio
n(allindo
orsetting900m
2 )
Youn
get
al.
2006
[35]
RCT
Scho
ol:1
all-
girls
public
13.8±0.5years;100%
female;83.0%
African
Totesttheeffectiven
essof
alifeskills-orientated
PARecruitm
ent:
parent
&stud
ent
Self-repo
rtdaily
PA,self-
CertifiedPE
teache
rsat
the
81totalP
Eclasses(41
Individu
al&
team
sports(e.g.,
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 13 of 26
Table
1Metho
dologicalcharacteristicsof
second
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
(Con
tinued)
high
scho
ol,
9thgrade
Stud
ent:221
girls
American,56.3%
ofgirls’m
othe
rshada
high
scho
oled
ucation.SESNR
BaltimoreMagne
tHighScho
ol,U
SA
interven
tion,cond
uctedin
PEclassby
ateache
rhiredby
theproject,forincreasing
PA&fitne
ssin
9thgradegirls
Group
A=standard
PEclass
(con
trol).
orientation
meetin
gs,m
ass
mailings
toparents,
classroo
mpresen
tatio
nsto
stud
ent.
Stud
ents
recruitedover
3successive
years.
Inform
edconsen
tfro
mparent/le
gal
guardian.
Respon
serate:
50%
(221/442),
95%
retention
repo
rtsede
n-tary
activities,
cardiorespira-
tory
fitne
ss,
CVD
riskfactors
(e.g.,BM
I,waist
circum
ference,
bloo
dpressure)
SOFIT
(mod
ified
version)
scho
ol(con
trol
only)
Baselinemeasures
inSept
control),45
min
classlesson
basketball).
Specificsports
NR
PAph
ysical
activ
ity,SOFITSystem
forObserving
FitnessInstructionTime,HRHeartrate,yrsyears,MVP
Amod
erate-to-vigorou
sph
ysical
activ
ity,P
Eph
ysical
education,
NRno
trepo
rted
,NSW
New
SouthWales,SSR
Small
Screen
Recreatio
n,PA
LDCPh
ysically
Activein
Ling
uistically
Diverse
Com
mun
ities,B
MIB
odyMassInde
x,incl.including
,SDTSelf-DeterminationTh
eory,TAAGTrialo
fActivity
forAdo
lescen
tGirls,VP
Avigo
rous
physical
activ
ity,M
PAmod
erateph
ysical
activ
ity,LPA
light
physical
activ
ity,m
inminutes,R
CTRa
ndom
ised
Con
trolledTrial,CV
Dcardiovascular
disease,
e.g.,for
exam
ple.
i.e.,that
isa Sen
ateBill42
requ
iredmiddle-scho
olchild
renin
Texasto
participatein
30min
MVP
A/day
oraminim
umof
135min/w
eekor
225min/fortnight.C
hildrenmustalso
participatein
PEfor4/6semestermiddle
scho
olcycles
bWas
notpo
oled
into
ameta-an
alysisas
only
onelesson
observed
andhe
nceno
mean(SD)isrepo
rted
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 14 of 26
Table
2Summarytableof
thefinding
sof
thesecond
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
Reference:firstauthor
&year
Measure
Group
AGroup
BGroup
CGroup
D
Lesson
s(n)
MVPA,
meanmins
±SE/(SD
)
Minsob
s,mean±
SE/(SD
)
%MVP
A,
mean±
SE/(SD
)
Lesson
s(n)
MVPA,
meanmins
±SE/(SD
)
Minsob
s,mean±
SE/(SD
)
%MVP
A,
mean±
SE/(SD
)
Lesson
s(n)
MVPA,
meanmins
±SE/(SD
)
Minsob
s,mean±
SE/(SD
)
%MVPA,
mean±
SE/(SD
)
Lesson
s(n)
MVP
A,
meanmins
±SE/(SD)
Minsob
s,mean
±SE/(SD
)
%MVP
A,
mean±
SE/(SD
)
MiddleScho
ols
Barrosoet
al.
2009
[36]
SOFIT
46NR
51.3(NR)
54.9±5.1
––
––
––
––
––
––
Coe
etal.
2006.[32]
SOFIT
NR
19(NR)
~55
(NR)
~34.5
(NR)
––
––
––
––
––
––
Fuet
al.
2013
[27]
Ped
170.35(12.82)
step
s/min
~50
(NR)
<50%
(NR)
161.28(11.84)
step
s/min
~50
(NR)
<50%
(NR)
––
––
––
––
Gao
etal.
2011
[37]
Total
Accel
3~59.96(NR)
~90
(NR)
66.62
(17.23)
––
––
––
––
––
––
Health
yweigh
t3
~61.35(NR)
~90
(NR)
68.17
(15.56)
––
––
––
––
––
––
Overw
eigh
t/ob
ese
3~55.03(NR)
~90
(NR)
61.14
(21.54)
––
––
––
––
––
––
Liuet
al.
2013
[34]
SOFIT
43NR
NR
46.10
(9.77)
––
––
––
––
––
––
McKen
zieet
al.
2006
[29]
SOFIT
431
13.9(7.0)
37.3(9.4)
37.9
(18.5)
––
––
––
––
––
––
Sprin
geret
al.
2013
[38]
SOFIT
84NR
NR
50.9
(15.0)
––
––
––
––
––
––
Second
aryScho
ols
Bron
ikow
ski
etal.2005[ 23]
Boys
HR
39~13.9(NR)
~45
(NR)
36.5(NR)
38~25.3(NR)
~45
(NR)
46.0(NR)
––
––
––
––
Girls
32~13.8(NR)
~45
(NR)
34.4(NR)
40~23.3(NR)
~45
(NR)
40.9(NR)
––
––
––
––
Cho
wet
al.
2009
[45]
Total
SOFIT
238
19.8(8.9)
57.1(NR)
34.8
(13.0)
––
––
––
––
––
––
Boys
9221.0(9.7)
57.1(NR)
38.2
(14.7)
––
––
––
––
––
––
Girls
108
18.5(7.8)
57.1(NR)
31.8
(12.5)
––
––
––
––
––
––
Co–
ed38
20.4(9.3)
57.1(NR)
35.3
(12.5)
––
––
––
––
––
––
Con
leyet
al.
2011
[26]
HR
128
(6.4)
~54
(NR)
51.9
(11.9)
––
––
––
––
––
––
Dud
leyet
al.
2012a[39]
&Dud
leyet
al.
2012b[40]
SOFIT
8133.6(11.1)
59(NR)
56.9
(18.7)
51~30.7(NR)
59(NR)
52.1
(24.1)
––
––
––
––
Faircloug
het
al.
2005
[12,19]&
Faircloug
het
al.
2006
[20]
a
HR
HR
119.6(NR)
59.1(NR)
33.2
(7.4)a
124.8(NR)
85(NR)
29.2
(20.6)
a–
––
––
––
–
SOFIT
SOFIT
1~7.6(NR)
59.1NR)
12.9
(NR)
a1
~14.9(NR)
85(NR)
17.5
(NR)
a–
––
––
––
–
Ferriera
etal.
2014
[24]
Total
Accel
125.36(15.69)
90(NR)
28.18
(NR)
a–
––
––
––
––
––
–
Boys
Accel
128.95(16.02)
90(NR)
––
––
––
––
––
––
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 15 of 26
Table
2Summarytableof
thefinding
sof
thesecond
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
(Con
tinued)
32.17
(NR)
a
Girls
Accel
121.58(14.48)
90(NR)
23.98
(NR)
a–
––
––
––
––
––
–
12years
Accel
121.58(14.48)
90(NR)
23.98
(NR)
a–
––
––
––
––
––
–
13years
Accel
130.40(16.20)
90(NR)
33.77
(NR)
a–
––
––
––
––
––
–
14years
Accel
129.69(18.92)
90(NR)
32.99
(NR)
a–
––
––
––
––
––
–
15years
Accel
125.82(16.14)
90(NR)
28.69
(NR)
a–
––
––
––
––
––
–
16years
Accel
123.33(13.37)
90(NR)
25.93
(NR)
a–
––
––
––
––
––
–
17years
Accel
122.35(14.39)
90(NR)
24.83
(NR)
a–
––
––
––
––
––
–
Hanno
net
al.
2005
[21]
Boys
Ped
NR
87.1(10.6)
step
s/min
~20
(NR)
~50%
(NR)
NR
88.8(9.5)
step
s/min
~20
(NR)
>50%
(NR)
––
––
––
––
Girls
NR
66.2(6.3)
step
s/min
~20
(NR)
<50%
(NR)
NR
57.9(8.6)
step
s/min
~20
(NR)
<50%
(NR)
––
––
––
––
How
etal.
2013
[33]
Total
Accel
32~8.4(NR)
~40
(NR)
21.12
(6.22)
––
––
––
––
––
––
Boys
Accel
16~9.3(NR)
~40
(NR)
23.15
(5.68)
––
––
––
––
––
––
Girls
Accel
16~7.6(NR)
~40
(NR)
19.11
(6.12)
––
––
––
––
––
––
Krem
eret
al.
2012
[41]
Accel
26~10.29(NR)
~35
(NR)
29.4
(24.0)
25~9.94
(NR)
~35
(NR)
28.4
(25.3)
23~9.56
(NR)
~35
(NR)
27.3
(26.2)
––
––
Lonsdaleet
al.
2013
[28,54]
Base
Accel
167.25
±NR
20±NR@
36.25±
9.54
168.14
±NR
20±NR@
40.70±
9.47
167.03
±NR
20±NR@
35.15
±9.46
167.58
±NR
20±NR@
37.88±
9.46
F/U
167.29
±NR
20±NR@
36.47±
9.54
––
––
––
––
––
––
Owen
etal.
2013
[44]
Accel
120.39(14.10)
60(NR)
33.99
(11.95)
––
––
––
––
––
––
Sand
erset
al.
2014
[25]
Accel
12NR
NR
36.0
(12.3)
––
––
––
––
––
––
Scrugg
set
al.
2010a[46]
Overall
SOFIT
&Ped
1615.88(8.27)
54.89
(10.19)
29.27
(13.60)
1626.50(13.40)
54.89
(10.19)
46.96
(18.26)
1615.17
(7.99)
54.89
(10.19)
30.51
(14.82)
––
––
Boys
1618.02(7.84)
54.89
(10.19)
35.15
(13.86)
1629.71(12.50)
54.89
(10.19)
54.25
(16.33)
1612.33
(7.79)
54.89
(10.19)
37.10
(14.36)
––
––
Girls
14.22(8.25)
54.89
(10.19)
24.72
(11.55)
24.19(13.62)
54.89
(10.19)
41.70
(17.83)
18.10
(7.14)
54.89
(10.19)
24.12
(12.31)
––
––
Tradition
al9
10.51(5.77)
36.72
(4.42)
29.59
(17.33)
916.80(8.57)
36.72
(4.42)
44.92
(23.18)
910.73
(5.64)
36.72
(4.42)
31.26
(18.02)
––
––
Block
722.12(6.07)
76.19
(4.17)
28.90
(7.24)
737.57(8.38)
76.19
(4.17)
49.30
(9.70)
722.44
(5.57)
76.19
(4.17)
29.28
(6.92)
––
––
Overall
Ped
4017.59(9.97)
––
––
––
––
––
––
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 16 of 26
Table
2Summarytableof
thefinding
sof
thesecond
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
(Con
tinued)
Scrugg
set
al.
2010b[47]
49.69
(19.77)
35.88
(15.83)
Boys
4021.29(13.99)
NR
43.01
(13.99)
––
––
––
––
––
––
Girls
4013.96(8.64)
NR
28.88
(14.38)
––
––
––
––
––
––
Tradition
al30
13.34(6.56)
36.88
(4.07)
36.63
(17.53)
––
––
––
––
––
––
Block
1027.17(10.03)
78.56
(5.08)
34.20
(11.03)
––
––
––
––
––
––
9th–10th
grade
2621.91(11.61)
NR
39.24
(13.95)
––
––
––
––
––
––
11th–12th
grade
2713.87(6.28)
NR
32.99
(16.82)
––
––
––
––
––
––
Surapido
onchaietal.
2012
[43]
Middle
scho
olSA
M3
NR
NR
50.0
(30.8)
––
––
––
––
––
––
Highscho
ol2
NR
NR
36.5
(46.0)
––
––
––
––
––
––
Vido
niet
al.
2012
[31]
HR
4NR
~35
(NR)
43.1
(19.17)
––
––
––
––
––
––
Wanget
al.
2005
[22]
Total
HR
727.9(23.9)
61.2(NR)
~45.6
(NR)
146.7(4.0)
29.5(NR)
~22.7
(NR)
––
––
––
––
Boys
729.7(23.7)
61.2(NR)
~48.5
(NR)
78.3(4.6)
29.5(NR)
~28.1
(NR)
––
––
––
––
Girls
726.1(25.8)
61.2(NR)
~42.6
(NR)
75.0(2.6)
29.5(NR)
~16.9
(NR)
––
––
––
––
Youn
get
al.
2006
[35]
Girlson
lySO
FIT
b41
~13.7(NR)
~45
(NR)
30.5(NR)
––
––
––
––
––
––
minsminutes,o
bsob
servations,M
VPAMod
erate-to-vigorou
sph
ysical
activ
ity,SEstan
dard
error,stan
dard
deviationstan
dard
deviation,
base
baselin
e,F/Ufollow-up,
NRno
trepo
rted
,HRhe
artrate
mon
itorin
g,SO
FITSystem
forObserving
FitnessInstructionTime,Co
-edCo-ed
ucationa
l;~estim
ated
valuecalculated
from
thestud
yresults
prov
ided
;@on
lyaprop
ortio
nof
thetotalP
Elesson
was
observed
a Rep
ortedtotala
ndstan
dard
deviationno
trepo
rted
.Was
notpo
oled
into
ameta-an
alysisas
onlyon
elesson
observed
bMod
ified
versionof
SOFIT
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 17 of 26
studies (n = 2), quasi-experimental RCT (n = 1), clusterRCT (n = 1), single subject multi-element study (n = 1)and a group randomised serial cross-sectional study (n = 1).Of the 12 studies that were not of cross-sectional nature,six studies contributed baseline intervention and/or controlgroup data to the systematic review [19, 20, 26–31] andthe remaining six studies contributed only controlgroup data at follow-up [21, 23, 32–35].The eligible studies were conducted in 88 middle
schools and 77 high schools. Six of the seven middleschool studies reported data on both male and femalestudents and did not separate results by sex [27, 32, 34,36–38] and one study reported a female only sample [29].Six of the 18 high school studies [26, 30, 31, 39–43] re-ported data on both male and female students and did notseparate results by sex. Of the remaining 12 high schoolstudies, two were conducted with a female only sample[19, 20, 35], two with a male only sample [25, 44], andeight examined both male and female students and re-ported results separately for each sex [21–24, 33, 45–47].Twelve studies measured MVPA through observa-
tional measures (e.g., SOFIT) [19, 20, 29, 32, 34–36, 38–40, 43, 45–47], seven used accelerometers [24, 25, 28,33, 37, 41, 44], five used heart rate monitors [19, 20, 22,23, 26, 31] and four used pedometers [21, 27, 46, 47].The majority of middle school studies assessed physicalactivity through observational measures (n = 5/7).Studies in a high school setting used a range of measure-ment tools including observation methods (n = 7), accel-erometry (n = 6), heart rate monitoring (n = 5), andpedometers (n = 3). Three high school studies used twomethods of PE lesson monitoring [19, 20, 46, 47].The number of PE lessons observed in each study
ranged from 1–431. In total, more than 609 middleschool PE lessons and 837 high school PE lessons weremonitored. One middle school study [32] and one highschool study [21] did not report number of lessons mon-itored. Lesson length was highly variable in both middleschool (range: 37–90 min/lesson) and high schools(range: 20–90 min/lesson). All middle school studies(n = 7/7) and the majority of high school studies (n = 15/18)monitored PE lessons that were led by PE teachers, spe-cialists or instructors. The remaining studies did notstate who led the PE lesson [23, 41, 44]. The randomeffects model was used for main and moderatormeta-analyses as there was heterogeneity among thestudies (main meta-analysis: Q = 455.8, df = 14, p < 0.001,I2 = 96.9%; moderator analysis by school level: middleschool Q = 70.6, df = 4, p < 0.001, I2 = 94.3%, highschool Q = 274.4, df = 9, p < 0.001, I2 = 96.7%; moder-ator analysis by type of physical activity measurement:observational methods Q = 183.7, df = 7, p < 0.001, I2 =96.2%, accelerometer methods Q = 49.1, df = 4, p < 0.001,I2 = 91.9%).
Risk of biasThe risk of bias coding criteria and results of theappraisal are outlined in Table 3. The representativenessof the school, class and student sample were the primarysources of potential bias. Few studies demonstrated thati) the schools examined were representative of otherschools (n = 5), ii) the classes chosen to be monitoredwere representative of all classes (n = 9), or iii) thestudents chosen to be monitored were representative ofthe population (n = 12). All studies adequately describedthe demographic characteristics of the school sample.The majority of studies used an objective measure ofphysical activity or cited validation studies (n = 22) andstated reliability data (n = 22).
MVPA in secondary school PE lessonsOf the 25 studies included in the systematic review, thepercentage of PE lesson time spent in MVPA rangedbetween 12.9 and 68.2%. Fifteen studies provided thenecessary data to be pooled into a meta-analysis. The pooledanalysis of these studies (Fig. 2) showed that the mean(95% CI) percentage of PE lesson time that secondaryschool students spent in MVPA was 40.5% (34.8–46.2%).
Moderator analyses
� Student participation in MVPA during PE by schoollevel (middle vs high school)Of the 15 studies included in the meta-analysis, fivewere conducted in middle schools and 10 in highschools. Middle school students spent a mean(95%CI) of 48.6% (41.3–55.9%) of PE lesson timein MVPA in comparison to 35.9% (28.3–43.6%)of PE lesson time spent in MVPA by highschool students (Fig. 3).
� Student participation in MVPA during PE byphysical activity measurement typeFive of the 15 studies in the meta-analysisassessed MVPA with accelerometers, nine usedobservational methods, one used heart rate moni-tors, and one used pedometers. One study usedboth observational measures and pedometers. Forstudies using accelerometers, students spent 34.7%(25.1–44.4%) of PE lesson time in MVPA (Fig. 4); incomparison to 44.4% (38.3–50.5%), 43.1% (24.3–61.9%)and 35.9% (31.0–40.8%) when measured usingobservational methods, heart rate monitors andpedometers, respectively.
� Student participation in MVPA during PE by PElesson typeAn analysis to examine whether MVPA in lessontime differed by lesson type was not conducted dueto a lack of detailed information provided on PEactivities. While nine of the 15 studies included in
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 18 of 26
Table
3Summaryof
Risk
ofBias
assessmen
tforthesecond
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
Ref:firstauthor
andyear
Scho
olslevel
Class
level
Stud
entlevel
PElesson
observation
1.Ade
quately
describ
edthe
demog
raph
iccharacteristics
ofthescho
olsample
2.Scho
olsamplewas
represen
tative
3.Class
chosen
was
representative
ofallclasses
4.Ade
quately
describ
edthe
demog
raph
iccharacteristics
oftheclass
sample
5.Ade
quately
describ
edthe
eligibility
criteria
6.Ade
quately
describ
edthe
demog
raph
iccharacteristics
ofthestud
ent
sample
7.Stud
entsample
represen
tativeof
thepo
pulatio
n
8.Described
thenu
mbe
rof
PElesson
sob
served
9.Objective
measure
ofPA
orcitedvalidation
stud
ies/stated
validity
data
10.O
bjective
measure
ofPA
orstated
reliability
data/citedreliability
studies
11.Rep
orted
thenature
ofthe
physicalactivities
observed
Middlescho
olstud
ies
Barrosoet
al.
2009
[36]
YY
UY
YN
UY
YY
N
Coe
etal.
2006.[32]
YY
YN
NN
YY
NN
N
Fuet
al.
2013
[27]
YU
UY
YY
UY
YY
Y
Gao
etal.
2011a[37]
YU
UY
YY
UN
YY
Y
Liuet
al.
2013
[34]
YU
YY
YY
UN
NN
N
McKen
zie
etal.2006[29]
YU
UN
NN
UY
YY
N
Sprin
ger
etal.2013
[38]
YU
YY
YY
YY
YY
N
Highscho
olstud
ies
Bron
ikow
ski
etal.2005[23]
YU
UN
NN
UN
YY
Y
Cho
wet
al.
2009
[45]
YY
YY
YN
YY
YY
Y
Con
leyet
al.
2011
[26]
YU
UY
YY
UY
YY
Y
Dud
leyet
al.
2012a[39]
&Dud
leyet
al.
2012b[40]
YN
YY
YY
YY
YY
N
Faircloug
het
al.2005
[12,19]&
Faircloug
het
al.2006
[20]
YU
UY
YY
YY
YY
Y
Ferriera
etal.
2014
[24]
YY
YY
YY
YY
YY
Y
Hanno
net
al.2005
[21]
YU
UY
YN
UN
YY
Y
How
etal.
2013
[33]
YU
UY
YN
NY
YY
Y
Krem
eret
al.
2012
[41]
YY
YY
NY
YN
YY
N
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 19 of 26
Table
3Summaryof
Risk
ofBias
assessmen
tforthesecond
aryscho
olPE
lesson
stud
iesinclud
edin
thesystem
aticreview
(Con
tinued)
Lonsdaleet
al.
2013
[28,54]
&Ro
senkranz
etal.2012[30]
YN
UY
YY
YN
YY
Y
Owen
etal.
2013
[44]
YU
YY
YY
YN
YY
N
Sand
erset
al.
2014
[25]
YU
UY
YY
UY
YY
Y
Scrugg
set
al.
2010a[46]
YU
UY
YY
UY
YY
N
Scrugg
set
al.
2010b[47]
YU
UY
YY
UY
YY
Y
Surapibo
onchai
etal.2012[43]
YN
UY
YY
YN
YY
Y
Vido
niet
al.
2012
[31]
YU
UY
YY
UN
YY
Y
Wanget
al.
2005
[22]
YU
UY
YY
YY
YY
Y
Youn
get
al.
2006
[35]
YU
YY
YY
YY
NN
U
Each
crite
riawas
code
das
‘clearlyde
scrib
edan
dpresen
t’(yes;Y
),‘absen
t’(no;
N),or
‘unclear
orinad
equa
tely
describ
ed’(un
clear;U)ratin
gforeach
ofthe11
items
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 20 of 26
the meta-analysis provided details on the type/s ofphysical activity that students were engaged in, themajority (7/9 studies) reported on lessons that in-cluded activities that fell into multiple categories(fitness orientated activities, team invasion games,dance and gymnastics or net game activities) and theproportion of time spent in MVPA was not reportedseparately for each lesson type.
DiscussionSummary of the evidenceThis systematic review and meta-analysis aimed to de-termine the proportion of secondary (middle and high)school PE lesson time that students spend in MVPA. Ofthe 25 studies found, the proportion of time spent inMVPA varied considerably between 12.9 and 68.2% oflessons. The meta-analysis of 15 studies found that theproportion of lesson time spent in MVPA is typicallybelow the US CDC [9] and UK AfPE [11] recommenda-tion of 50% of PE lesson time, with only 40.5% ofsecondary school lesson time spent in MVPA. Middleschool students were found to spend a higher proportionof lesson time in MVPA (48.6%) in comparison to high
school students (35.9%), although there was considerablevariability in the proportions from both groups. Resultsdiffered according to the method of MVPA assessment,ranging from 34.7% in accelerometer-assessed lessons to44.4% for observational-assessed studies. Caution shouldbe taken when interpreting these finding as the confi-dence intervals for the moderator analyses overlappedand only one study reported findings using heart ratemonitors and pedometers. The heterogeneity in studyfindings may be due to the different ages of the studentsand the different types of activities in PE (which wereoften not reported). The studies also differed in theirmeasurement protocols, such as using a variety of meas-urement instruments (e.g., accelerometers vs SOFIT)with different definitions of reporting time (e.g., sched-uled lesson vs actual lesson length), which may have alsocontributed to the heterogeneity in results between thestudies. We were unable to explore differences in MVPAaccording to lesson type due to a lack of detailed infor-mation and data provided on PE activities.The findings of the overall proportion of MVPA in PE
lessons (40.5%) are broadly similar to the previous sec-ondary school review on this topic published in 2005[12] which reported the proportion of PE lesson time
Study name Subgroup within study Comparison Statistics for each study Mean and 95% CI
Standard Lower Upper
Relative weight
Mean Error Variance Limit Limit Z-Value
Barroso et al 2009 Total Observation 54.90 5.10 26.025 44.901 64.899 10.762 6.41
Chow et al 2009 Total Observation 34.80 0.84 0.71 33.148 36.452 41.298 7.95
Dudley et al 2012 a & b Combined Observation 55.04 1.82 3.33 51.464 58.627 30.124 7.76
Gao et al 2011 Total Accelerometer 66.62 9.94 98.958 47.123 86.117 6.69 4.12
How et al 2013 Total Accelerometer 21.12 1.10 1.20 18.965 23.275 19.208 7.91
Kremer et al 2012 Combined Accelerometer 28.40 2.88 8.31 22.758 34.061 9.85 7.42
Lonsdale et al 2013 Combined Accelerometer 37.22 4.14 17.168 29.103 45.345 8.98 6.88
Lui et al 2013 Total Observation 46.10 1.49 2.22 43.180 49.020 30.941 7.84
McKenzie et al 2006 Total Observation 37.90 0.89 0.79 36.153 39.647 42.531 7.94
Sanders et al 2014 Total Accelerometer 36.00 3.55 12.608 29.041 42.959 10.139 7.15
Scruggs et al 2010a Total Observation 30.510 5.24 27.454 20.240 40.780 5.82 6.34
Scruggs et al 2010b Total Pedometer 35.88 2.50 6.26 30.974 40.786 14.335 7.55
Springer et al 2013 Total Observation 50.90 1.63 2.67 47.692 54.108 31.100 7.81
Sura... et al 2012 Combined Observation 44.60 14.546 211.599 16.089 73.111 3.06 2.65
Vidoni et al 2012 Total Heart Rate 43.10 9.58 91.872 24.314 61.886 4.49 4.2740.47 2.89 8.39 34.800 46.156 13.972
-100.00 -50.0 0.00 50.0 100.0
Fig. 2 Individual study and pooled results of the percentage of secondary school PE lesson time spent in MVPA
Fig. 3 Individual study and pooled results of the percentage of middle and high school PE lesson time spent in MVPA
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 21 of 26
spent in MVPA separately according to the type ofmeasurement instrument used, ranging between 27–47%of the lesson. There were variations in findings betweenthe two reviews according to the type of measurementinstrument used. For example, accelerometer-measuredlessons reported the lowest levels of MVPA in thepresent review (34.7%) and the highest proportionMVPA in the previous review (46.8%) [12]. The variationin findings may be explained by differences in method-ology between the two reviews; the 2005 review was nota systematic review, did not assess risk of bias and ameta-analysis was not conducted so we are unable tocomment on any biases of the component studies whichmay have influenced the results. The proportion ofstudies assessed using different measurement instru-ments also varied between the two reviews, which mayhave influenced the findings since different instrumentsmay be associated with different types of bias. Forexample, of the 15 studies included in our meta-analysis,9 studies used observational measures. Whilst this is asimilar number as in the previous review, it forms ahigher proportion of the studies (60% v’s 25%). Meth-odological inconsistencies between the measurement in-struments (e.g., length of the monitored PE lesson andthe measurement of different elements of activity tocalculate MVPA) make it difficult to draw firm conclu-sions. The implications of methodological inconsisten-cies and potential biases are discussed in more detailbelow. Regardless of the type of measurement methodused, the findings suggest that overall little progress hasbeen made in engaging adolescents in more MVPAduring PE lessons.Some differences in MVPA levels were observed
between studies in the middle and high school setting.The moderator analyses found that, on average, studentsin middle school PE lessons were observed to be al-most meeting the US CDC [9] and UK AfPE [11] rec-ommendation with 48.6% (41.3–55.9%) of lesson time
being spent in MVPA, compared with 35.9% (28.3–43.6%)of PE lesson time in high schools. In a recent meta-analysis on MVPA in elementary school PE lessons usingthe same methodology [17], elementary school studentswere found to engage in MVPA for 44.8% (28.2–61.4%) ofthe PE lesson. As the confidence intervals for the elemen-tary, middle and high school analyses overlap, the findingssuggest that the level of MVPA in PE across each schoolsetting are relatively comparable. Caution should be takenin interpreting the school level specific results as it is un-clear whether the seeming decline in MVPA in PE lessonsfrom middle school to high school was a result of the typeof measurement instruments used rather than the schoolsetting. For example, four of the five (80%) middle schoolstudies included in the meta-analysis assessed MVPAusing observational methods, in comparison to four of ten(40%) high school studies. The previous review did notexamine MVPA in middle and high school PE lessons sep-arately, so we are unable to comment on progress inthe different secondary school settings.As all middle school studies were conducted in the
USA, the generalisability of the middle school findingsto other countries is unclear. Middle schools in the USAnormally enrol students aged between 11–13 years old(6th - 8th grade), although this can vary depending onschool districts. This age range spans both elementaryand high school ages in other countries such as the UKand Australia. Further research reviewing MVPA inmiddle school lessons outside of the USA is needed toexamine whether the observed level of MVPA in middleschool PE lessons is uniform or isolated to the USA.Gaining a better understanding of the strategies imple-mented to build active lessons in middle school PElessons in the USA may provide insight to build moreactive lessons in high schools. Continuing to intervenewithin the middle school setting remains important forboth maintaining activity levels and ensuring activity isundertaken equally across the student population.
Fig. 4 Subgroup meta-analysis of the percentage of secondary school PE lesson time spent in MVPA according to measurement method (accelerometers,heart rate monitors, observational methods and pedometers)
Hollis et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:52 Page 22 of 26
Barriers to delivering more active PE lessons have beendescribed as institutional (e.g., school policies, a crowdedcurriculum, limited facilities and equipment, and insuffi-cient departmental assistance), teacher-related (e.g., re-lated to teachers’ beliefs, skills and confidence) orstudent-related (e.g., lack of student motivation andinterest) [48]. In comparison to elementary schools,fewer teachers-related barriers are reported in secondaryschool studies where a lack of student motivation andinterest emerge as barriers in PE [49]. Evidence suggeststhat motivation for physical activity engagement maychange with maturation [50]. Intrinsic motivation (i.e.,enjoyment of the activity) appears to play a leading rolein physical activity participation among children, whileother forms of autonomous motivations such as identifiedregulation (i.e., the outcome is identified as personally im-portant), become more important among adolescents [50]and adults [51]. Numerous cross-sectional studies haveidentified positive associations between controlled andautonomous forms of motivation and physical activity inyoung people [52], yet empirical studies demonstratingthe effect of school-based interventions on student motiv-ation is lacking. There is a clear need for high qualityexperimental research to evaluate the impact of teacherprofessional learning interventions on secondary schoolstudents’ motivation and MVPA in PE lessons [50] andalso to determine any subsequent effects on leisure-timephysical activity.
Risk of biasThe representativeness of the school, class and studentsample were the primary sources of potential bias aslimited information was provided to determine whethereach of these samples were representative of the targetpopulation and the studies representative of usual PElessons. This is not surprising given that many of thestudies provided opportunistic data from trials ratherthan a purposeful sample for PE lesson proportion esti-mation. As previously noted, all middle school studieswere conducted in the USA and the generalisability offindings to other countries for this age group is unclear.Varied definitions of ‘reporting time’ between different
instruments made it challenging to compare studies andmay explain some of the differences in findings. Somestudies calculated the proportion of MVPA time usingthe time of the total scheduled PE lesson (e.g., a 60-minlesson) while other studies only monitored physicalactivity for the time when students are engaged in activ-ity or when a specified proportion of the class are inattendance. For example, accelerometer-assessed lessonstypically monitor MVPA for the duration of the sched-uled lesson based on school timetables, while the SOFITobservational method monitors student physical activitylevels once 51% of students are present, and concludes
when 51% of students have left the lesson [53]. In-consistencies in reporting time, whether stated or not,may distort the results and provide an inaccurate rep-resentation of true MVPA time to compare againstCDC recommendations [17]. Each instrument alsomeasures different elements of activity to calculateMVPA. For example; accelerometers measure activityusing the number of counts above certain cut-points,pedometers according to the number of steps/min,heart rate monitors according to heart rate levelsabove certain cut-points, and SOFIT uses movementcategories. Some forms of activity may be categoriseddifferently depending on the instrument used; forexample, SOFIT classifies walking as MVPA while anon-brisk walking pace measured using accelerome-ters is unlikely to be considered MVPA [17]. Studiesthat used accelerometers to measure physical activityused different accelerometer cut-points to defineMVPA (e.g., >1500 [37], >1962 [24] and >2001 [41]counts/min), which may have also contributed to thevariation in findings between studies and made itdifficult to compare and summarise the findings.
Strengths and limitationsThis review provides a systematic synthesis of pro-gress in achieving physically active PE lessons. Thereview included objectively-measured physical activitylessons and also included the addition of pedometer-assessed physical activity in PE lessons. Two moder-ator analyses were conducted to assess if MVPAdiffered according to middle or high school PE lessonand type of measurement method. A meta-analysiswas conducted to provide an overall pooled estimateof MVPA in secondary schools, as well as for themoderator analyses. The systematic review has somelimitations. Seven studies did not provide adequatedata to be pooled in to the meta-analysis and, despiteseveral attempts, the study authors were unable to becontacted or were unable to provide the necessaryadditional information and data. In addition, a furtherthree studies provided data based on one lesson andcould not be included in the meta-analysis. As a re-sult, only 15 of the 25 studies were included in themeta-analysis. We did not include any inclusion cri-teria about probability sampling for any of the studydesigns. The review was limited to studies that werepublished in English and in prominent databases. Thismay not be inclusive of all studies investigatingMVPA in PE and published between 2005 and 2014.Studies related to MVPA in PE may appear in abroad range of journals including both educationaland health fields, which may not always appear inprominent databases. We were unable to retrieve the-sis and conference abstracts.
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Recommendations for future research measuring activitylevels in PE lessonsInterventions designed to increase physically activelearning time in PE lessons have been recommended asone potential mode of increasing overall MVPA inadolescents, and to promote lifelong activity [54, 55].Intervention and observational studies investigatingphysical activity levels in PE lessons remain an import-ant contribution to monitoring progress in the field. Weoffer the following recommendations to improve thequality of future research:
1. Standardise the definition of ‘PE lesson time’:One solution could be reporting MVPA for lessonsthat monitor within a pre-specified proportion ofthe lesson (e.g., ≥90%) separately from lessons thatmonitor a smaller proportion of the scheduledlesson (e.g., <90%) [17]. Or at a minimum, stateboth the total allocated PE lesson duration and themonitoring time, if different.
2. Detailed reporting of MVPA outcomes: Comprehensivereporting is critical to fully monitor progress andmaximise the number of studies that are eligible forinclusion in systematic reviews. At minimum, futureobservation and intervention studies should state themean MVPA percentage of the lesson, a measure ofvariation (e.g., standard deviation), minutes ofMVPA and the number of lessons examined so thatdata can be pooled into a meta-analysis.
3. Report types of physical activities: Future studiesshould include a clear description of the activitiesundertaken, and if possible, provide activity resultsseparately for different types (e.g., fitness orientated,team invasion games, dance and gymnastics and netgame activities). This may be challenging if differenttypes of activity are undertaken within one lesson.
4. Ensure that PE lessons monitored are representative ofusual PE lessons: To increase the representativenessof the findings, studies should monitor lessons fromrandomly selected schools and classes. All studentswithin the lesson could be assessed, or a randomsample of students monitored. Studies should aim tomonitor numerous lessons (as many as feasible) asconclusions regarding the proportion of lesson timespent in MVPA can rarely be made from oneobservation. Information on the representativenessof the sample should also be provided.
5. Transparent and detailed reporting on study information:Many studies were excluded from the review as theylacked important information to confirm eligibility, andstudy authors were unable to be contacted. Reportingon the lesson context or structure (e.g., time spent inmanagement, knowledge, skill practice, game play andfitness), content (e.g., type of PE activities), delivery
(e.g., instructor behaviour) and environment (e.g.,where the lesson is delivered and weather) will alsoenable more comprehensive analysis in future reviews.
Increasing activity levels in secondary school PE lessonsPE is an opportunity to help students meet the 60 minof MVPA/day recommendation. Maximising MVPA inthe existing scheduled PE lesson time could be achievedthrough targeted strategies such as i) teacher profes-sional learning focused on reducing time spent in classmanagement, instruction and organisation and optimis-ing student motivation, and ii) by supplementing usualPE lessons with high intensity activity such as fitnessinfusion [54, 56–58]. Incorporating new technologies(e.g., Bluetooth pedometers that sync with apps) thatprovide real time individualised feedback and summariesof lesson physical activity levels could be tested as astrategy to motivate students and enable teachers tomonitor MVPA during PE. Beets et al. [59] haveproposed that future youth physical activity promotioninterventions be designed according to a frameworkreferred to as the Theory of Expanded, Extended andEnhanced Opportunities (TEO) using one or more ofthree mechanistic approaches: i) expansion – replacingtime allocated for low active/sedentary activities with anew occasion to be active, ii) extension – increasing thetime allocated for physical activity, and/or iii) enhance-ment – modifying existing physical activity opportunitiesto increase to amount of activity accumulated during anexisting period of time. Whatever approach is taken, it isimportant that PE teachers are supported to balance theneed of achieving active PE lessons while also meetingother curriculum and PE educational objectives. Meetingthe 50% MVPA target is only one aspect of measuringthe quality of PE lessons. Although the MVPA targetcould be achieved by asking students to run continuouslaps of an oval or gym, it is unlikely that this approachwill engage students in meaningful learning experiences,and may negatively impact on student’s attitudes, motiv-ation and engagement in physical activity [17, 50, 54].Not all PE lessons are conducive to high levels of MVPAbut may still be, for example, valuable for skill develop-ment, fitness, knowledge of movements and improvingsocial and emotional outcomes. For example, a gymnas-tics lesson may provide an opportunity for students topractice balance and rotation and involve cooperativelearning, and may not meet the 50% MVPA target.
ConclusionFew studies specifically examining MVPA in PE lessonshave been completed, and the studies that have beenconducted are difficult to compare due to diverse MVPAmeasurement methods and incomplete reporting ofMVPA outcomes. There is also limited data to comment
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on the generalisability of study findings. Based on theexisting evidence, PE lessons in the secondary schoolsetting fall short of the US CDC and UK AfPE recom-mendation of 50% of PE lesson time spent in MVPA.Although middle school PE lessons almost meet theMVPA recommendation, intervening in the middleschool setting remains important in maintaining activitylevels and ensuring that MVPA is undertaken equallyacross the student population. Further interventionresearch using the TEO framework [59] is needed tocapitalise on building active lesson time in to existing PElessons, working with schools to develop policies toensure PE lesson time is protected (i.e., not cancelled)and/or extending the curriculum time allocated to PE.Future studies which monitor PE lessons in secondaryschools should aim to incorporate the recommendationsmade in this review in to the study design to facilitatemore accurate and comprehensive monitoring of MVPAin PE lessons.
Additional file
Additional file 1: A record of the search strategy used for eachdatabase. (DOCX 24 kb)
Additional file 2: 11-item risk of bias tool developed for the systematicreview. (DOCX 14 kb)
Abbreviations95% CI: 95% confidence intervals; AfPE: Associations for physical education;CDC: Centre for disease control; MVPA: Moderate to vigorous physicalactivity; non-RCTs: Non-randomised controlled trials; PE: Physical education;PRISMA: Preferred reporting items for systematic reviews and meta-analysis;RCTs: Randomised controlled trials; SD: Standard deviation; SE: Standarderror; SES: Socioeconomic status; SOFIT: System for observing fitnessinstruction time; UK: United Kingdom; USA: United States of America
AcknowledgementsThe authors would like to acknowledge Debbie Booth, a Research Librarianat the University of Newcastle, who assisted in refining the search strategyand conducted the database searches.
FundingInfrastructure support was received from the Hunter Medical ResearchInstitute (HMRI) and Hunter New England Population Health. DRL issupported by an Australian Research Council Future Fellowship.
Availability of data and materialsAll data analysed during this study are included in this published article [andits Additional files].
Authors’ contributionsAll authors were responsible for the design of the study and the development ofthe search strategy. JLH and RS acted as first and second reviewer, respectively,and screened the studies, performed the risk of bias assessments and extractedstudy data. RS and JLH conducted the meta-analysis. EC acted as third reviewer,and resolved any disagreements during risk of bias assessments anddata extraction. JLH, RS, DL, PM and JW developed the risk of bias tool.NN developed the data extraction tool. JLH drafted the introduction, methods andresults section of the initial paper. JLH and RS drafted the discussion. All authorscontributed to the interpretation of the results and all drafts of the manuscript. Allauthors read and approved the final manuscript.
Competing interestsThe authors declare that they have no competing interests.
Consent for publicationNot applicable.
Ethical approval and consent to participateNot applicable.
Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.
Author details1Hunter New England Population Health, Locked Bag 10, Wallsend, NSW2287, Australia. 2School of Medicine and Public Health, University ofNewcastle, Callaghan 2308, Australia. 3Hunter Medical Research Institute,Lambton, NSW 2305, Australia. 4Priority Research Centre in Physical Activityand Nutrition, School of Education, University of Newcastle, Callaghan 2308,Australia.
Received: 1 September 2016 Accepted: 5 April 2017
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