1. Introduction
There is a well-documented overall positive effect of physical activity (PA) on mental health and well-being [
1]. Indeed, PA is widely recognized as an important determinant of physical and psychosocial health and development among children and adolescents [
1,
2,
3]. Although most adolescents report good mental health and quality of life, the prevalence of mental health challenges in this age group is increasing [
4]. Norwegian national representative data showed that from 2011 to 2016 the levels of mental health symptoms increased by 24% in adolescent girls [
5], and the prevalence of diagnosed mental illnesses in adolescent girls increased by 40% [
5]. Similar trends have been reported in other countries [
6,
7]. Simultaneously, there is a steady decrease in PA levels from childhood to adolescence in Norway [
8]. Many adolescents in Norway and other Western countries are insufficiently physically active to benefit from the positive factors of PA, as only about 50% of 15-year-olds meet the recommendation for daily PA [
9,
10,
11]. The World Health Organization (WHO) have launched a PA action plan [
12] aimed at reducing physical inactivity and a comprehensive school-based PA program [
13]. In addition, the WHO and UNESCO launched a global standard for health promotion in schools because schools are identified as a key arena for promoting health, well-being and a healthy lifestyle [
14].
Although Norway as a country has relatively high ratings on public health indicators compared with other countries [
15], Telemark County in Norway has a poor public health profile with a higher prevalence of mental health challenges and shorter life expectancy than average in Norway [
16]. To this end, the Telemark County Council initiated the Active and Healthy Kids program in 2016. This is a school-based, health-promoting program, which aims to improve living conditions for children and adolescents through increased school-based PA, healthier school meals and an improved psychosocial environment. One of the components, school-based PA, is built on the WHO’s comprehensive school-based PA program. PA in classrooms/physically active learning (PAL) is one important component and strategy to reach higher PA levels among children and adolescents [
17]. PAL is the use of PA as a pedagogical tool for learning academic content in other subjects than physical education (PE) [
18]. This strategy has been used by several school-based PA interventions [
19,
20,
21]. Most studies have examined the use of PAL in children [
22]; less is known about how early adolescents in secondary schools will respond to such an intervention. Studies on school-based PA and adolescents often use other strategies for increasing school-based PA, such as increasing the number of PE lessons and/or active breaks/recess [
23,
24].
The way we approach mental health has changed, and the concept of salutogenesis represents a shift from preventing mental health challenges, such as anxiety and depression, to promotion of well-being and quality of life [
25]. Using this perspective, positive emotions in early adolescents are linked to fewer relational problems and better work functioning in adulthood [
3]. The development of life skills, such as good health, has also been acknowledged as important and is included as part of the OECD Education 2030 [
26]. The effects of school-based PA interventions have mostly focused on improving physical fitness, reducing the risk of non-communicable diseases, increasing learning and decreasing mental-health challenges [
20,
27,
28,
29,
30,
31]. Less knowledge and attention have been given to the potential of school-based PA to improve health-related quality of life, vitality and well-being associated with increased school-based PA [
32]. Subjective vitality emerges as one component under the umbrella of well-being [
33], and is conceptualized as a psychological sense of aliveness, enthusiasm and/or energy. Nix and colleagues highlight that vitality has a regenerative capacity that is not necessarily representative of happiness but of broad emotional states, which is a common conception of well-being [
34]. Baily and Colleagues [
35] underline that positive development associated with PA does not occur automatically; PA’s contribution to well-being is conditional to the context and especially the social climate generated by, e.g., educators [
35]. To evaluate and get a more comprehensive picture of how a school-based PA program with PA and academic content combined affects adolescents’ health and well-being, we need to not only investigate the impacts on more objective outcomes like PA, cardiovascular indicators and aerobic fitness, but also well-being and sedentary time.
As mentioned, schools have been identified as a key setting to ensure adequate PA levels; however, a recent review from Love et al. [
36] finds that current school-based efforts do not positively impact young people’s PA across the full day. When looking at PA in school time, a recent meta-analysis from Norris et al. [
22] looked specifically at interventions using PAL and concluded that there is a positive effect of PAL on PA compared to a normal subject lesson. When looking at overall PA they found a non-significant or small effect [
22]. Because of a lack of results on PA across the full day, Love et al. [
36] recommend that, for now, school-based PA interventions should continue to be conducted in a research context. Further, Norris et al. states that more studies should include secondary schools and assessment of a more diverse range of health outcomes [
22]. This study aims to examine whether the Active and Healthy Kids program led to changes in PA, sedentary time, physical fitness, well-being and health-related quality of life (HRQoL) in early adolescents. The research questions were as follows: (1) do PA, physical fitness, well-being and HRQoL change in early adolescents following a school-based, health-promoting program? and (2) are there gender differences in the changes observed following the Active and Healthy Kids program?
4. Discussion
The main findings were the positive effects on school-based PA levels and the lack of effects on total PA level. Furthermore, we found positive effects on physical fitness and vitality in the total sample, and on vitality and domains of HRQoL among the girls. We found negative effects on sedentary time among the girls.
The program showed positive effects on school-based PA level across a full day. This is in accordance with findings from Dobbins et al. [
54], who reported that school-based PA interventions lead to more engagement in MVPA during school hours. In our study, the intervention group is stable over time in minutes spent in MVPA during school hours, where the control group declines. Similar results were found by Gammon et al. [
55] who implemented PAL in secondary schools [
55]. Because of the general decline in PA levels from child to adolescent, it is argued that interventions that attenuate PA decline could be considered effective [
56]. However, the analysis showed that only boys had significantly increased time spent in MVPA. This supports results from other studies, which found that both children and adolescent boys were more involved in MVPA than girls [
57,
58]. Increased PA during school supports finding by Norris et al. [
22]. The lack of effects on total PA level supports the results of Love et al. [
36], who found no positive effect of school-based PA across the full day. It must be emphasized that previous studies have mostly examined populations of children in elementary school, and these results are not necessarily transferable to adolescents in secondary schools. Potential challenges for PAL in secondary schools are age, pubertal status, a more advanced curriculum and learning outcomes, as well as a focus on academic testing. In addition, the general PA level is lower among adolescents compared to children [
8] and this might require more advanced skills in motivating and encouraging adolescents to actively participate in PAL. Furthermore, adolescence is a time period in life with large dropout rates from organized sports [
59], and this requires even greater efforts in order to improve total PA levels. Therefore, it can be argued that the observed effects on school-based PA level were more difficult to achieve than in the previous findings from elementary school. It must also be noted that the objective measurement of PA was conducted for four days (two weekdays plus Saturday and Sunday), and not for an entire week. This might have influenced the total PA level, since the inclusion of more weekdays in the measurement period would have provided measurement of more school hours as well.
As shown in another Norwegian school-based PA intervention that included PAL [
57], adolescents at the intervention schools increased cardiorespiratory fitness compared to the control schools. The intervention group also showed increased strength. This indicates that the activities in the school-based PA with emphasis on PAL had sufficient intensity and movement activities to achieve improvements in cardiorespiratory fitness and strength, resulting in overall improvements in physical fitness. Cardiorespiratory fitness is a powerful marker for health as it is associated with, among others, total abdominal adiposity, cardiovascular disease risk factors, positive effects on depression, anxiety, mood status and self–esteem [
60]. Hence, Ortega and colleagues conclude that health promotion policies and PA programs should be designed to improve cardiorespiratory fitness [
60]. However, the findings contradict those reported in the review of Norris et al. [
22], who conclude that PAL was not sufficient to improve cardiorespiratory fitness [
19,
61,
62].
The effects on vitality were shown by an actual reduction in vitality in the controls and a stability in vitality in the intervention group. The time period of early adolescence has previously shown that well-being can be impaired during this time [
63], hence the potential of implementing a school-based PA intervention with emphasis on PAL to prevent such impairments are very interesting.
There is compelling evidence that regular PA can have a positive effect on emotional well-being, especially the well-being of children and adolescents. PA is also linked to a variety of mental health outcomes [
1], yet this is to our knowledge the first study to show this effect using a school-based health promotion program with emphasis on PAL on adolescents. The positive findings on vitality and well-being indicate that the program holds some qualities that can improve the fulfilment of the three basic psychological needs that lead to intrinsic motivation and well-being, where vitality is an indicator [
49]. The specific effects on vitality and HRQoL observed among girls are interesting as this is the gender group where highest rates of mental health challenges are reported. The findings can be seen in relation to, e.g., Harrington et al. [
64], who found effects on self-esteem among girls following a school-based PA intervention. Especially interesting are the positive effects among girls on the HRQoL domains physical well-being, psychological well-being and autonomy and parents, in addition to their vitality. Improvement of these HRQoL domains might serve as a protector towards negative body image and body dissatisfaction in an age group with perceived pressure of achieving a certain type of body and appearance [
65]. In this study, the negative effect on sedentary time among girls is a result of an improvement in reduced sedentary time amongst girls in the control group. The girls from the intervention group did not increase their sedentary time during the study period nor did they significantly reduce their sedentary time. This program did not demonstrate any effectiveness for reducing pupils’ sedentary time on a full day or during school time in the short timeframe where pupils wore the accelerometers. The lack of results in reducing sedentary time in secondary schools is in accordance with a recently published pilot study from the UK, who found no evidence of reduced sedentary time after implementing PAL [
55]. This indicates the importance of examining levels of PA and sedentary time as individual and independent constructs [
66].
The findings are strengthened by use of an objective assessment of PA and physical fitness, as well as by validated instruments for assessment of vitality and HRQoL. The implementation by the Telemark County Council and the naturalistic setting increases the external validity of the findings. The non-randomized design is a limitation, and the power and sample size were small. Yet, this makes the statistically significant findings even more robust. Unfortunately, the delivery of the intervention is not systematically documented, and the naturalistic setting provide natural variations both within and between schools. Hence, the naturalistic setting is also a limitation to the internal validity of the results.
The results of this study should be viewed in light of the mentioned limitations. However, implications of the findings include the need for long-term follow-up in order to examine sustainability of the effects. Furthermore, examining the choice of activities and organizational forms during PAL lessons will provide more in-depth knowledge about the PA behavior in PAL.