reflection

sam1992

artical_2.pdf

R E S E A R C H A R T I C L E

Sixty Minutes of Physical Activity per Day Included Within Preschool Academic Lessons Improves Early Literacy STACIE M. KIRK, PhDa ERIK P. KIRK, PhDb

ABSTRACT BACKGROUND: The effects of increases in physical activity (PA) on early literacy skills in preschool children are not known.

METHODS: Fifty-four African-American preschool children from a low socioeconomic urban Head Start participated over 8 months. A 2-group, quasi-experimental design was used with one preschool site participating in the PA intervention and a second site participating as the control site. The PA program was designed to promote 300 minutes/week of moderate to vigorous PA academic lessons. Academic achievement related to early literacy and phonological awareness in the areas of rhyming and alliteration were assessed at baseline, 4 and 8 months.

RESULTS: Over 8 months, rhyming significantly (p < .01) improved in the PA group (173±12%) compared with the controls (28 ± 8%) resulting in between group differences at 8 months (p < .01). Alliteration significantly (p < .01) improved in the PA group (52 ± 16%) compared with controls (13 ± 5%), resulting in between group differences at 8 months (p < .01). As minutes of exposure to moderate to vigorous PA increased, the change in picture naming (R2 = .35, p < .05), alliteration (R2 = .38, p < .05), and rhyming (R2 = .42, p < .05), increased. CONCLUSION: A teacher-directed PA program is effective at increasing PA and improving early literacy.

Keywords: childcare/daycare; preschool curriculum; language/speech; Head Start; African Americans.

Citation: Kirk SM, Kirk EP. Sixty minutes of physical activity per day included within preschool academic lessons improves early literacy. J Sch Health. 2016; 86: 155-163.

Received on October 23, 2014 Accepted on March 26, 2015

Many children face significant challenges learningto read because they lack essential early literacy skills when they begin kindergarten.1,2 Children who are poor readers at the end of elementary school are most often those who failed to develop early literacy skills during preschool.3-5 Early literacy skills (phonological awareness, letter knowledge, print awareness) have been characterized as one of the new pre-K basics6,7 that are strongly correlated with the ability to read.4,8,9 Early literacy is comprised of several factors, including skills that form the foundation for the development of later conventional literacy skills (ie, decoding, reading comprehension, spelling, writing). The most prominent early literacy variables, including phonological awareness, letter

aAssociate Professsor, ([email protected]), Department of Special Education and Communication Disorders, Southern Illinois University Edwardsville, Edwardsville, IL 62026. bAssociate Professor, ([email protected]), Department of Kinesiology and Health Education, Southern Illinois University Edwardsville, Vadalabene Center, Suite 2616, Campus Box 1126, Edwardsville, IL 62026.

Address correspondence to: Erik P. Kirk, Associate Professor, ([email protected]), Department of Kinesiology and Health Education, Southern Illinois University Edwardsville, Vadalabene Center, Suite 2616, Campus Box 1126, Edwardsville, IL 62026.

This study was supported by an internal grant from Southern Illinois University at Edwardsville. The authors are grateful to all students and teachers who participated in our project.

knowledge, and print awareness, have medium to large predictive relationships with later literacy development.10 Decoding (translating printed word into sound), reading comprehension (understanding the meaning of written language), spelling, and writing are later literacy skills that are necessary components of literacy that are critical to successful elementary and secondary school outcomes.10 Whereas literacy skills encompass a broader range of abilities beyond reading, writing, and spelling, these are the literacy skills that were the focus of this work. Weaknesses in early literacy skills and subsequent reading failure are most common among low-income, non-White children and among children with limited proficiency in English.11

Compared with children from middle-income families,

children from economically disadvantaged families experience significant difficulties learning to read and write because they enter school with less knowledge of letters and less familiarity with words.12,13 The field of Early Childhood Education and Head Start in particular, has placed an increased emphasis on program improvement and accountability based on children’s outcomes. One of the outcomes targeted by Head Start programs includes development in the areas of literacy and language, which are critical to academic success.2,4,8,14 To this end, these findings emphasize the need for developing and establishing methods that can improve early literacy skills in preschoolers.

A novel approach to improving early literacy is academic lessons taught using physical activity (PA). PA has been shown to improve literacy skills in children aged 6-18 years.4,15-17 Carlson et al4

determined that there was a small but significant benefit in the areas of math and reading in kindergarten girls when enrolled in a higher amount (70-300 minutes) of PA. Other work18 has emphasized that the increase in blood and oxygen flow to the brain, and improved behavior in the classroom are possible mechanisms behind the benefit of PA on cognition. However, the effects of increases in PA on literacy skills in preschool children (ages 3 to 5), a critical time in literacy development are not known. Using academic lessons that incorporate PA directly into the preschool academic lessons offer an innovative approach to increasing PA during the school day without decreasing the time devoted to academics. Therefore, the purpose of this study was to evaluate the impact of academic lessons taught using 60 minutes of PA per day on the early literacy skills of rhyming and alliteration in Head Start preschools serving African- American children. We hypothesize that preschoolers that receive the academic lessons taught using PA will have a significantly greater increase in early literacy skills from baseline to 8 months compared with preschoolers at a nonexercising control preschool.

METHODS

Participants

Children. Parents provided written assent for their children and the children provided verbal consent. All students (N = 56) in both classrooms were eligible to, and did participate. There were a total of 54 (Intervention, N = 39; Control, N = 15) African- American preschool children (mean ± SE, age 4.1 ± 0.2 years) from an urban Head Start program that completed the 8-month study (Table 1). Two students (one from each group) dropped out from the study because of moving away from the school. Over 99% of families enrolled in the Head Start program were African Americans and >95% of families were categorized as living below the poverty line.

Table 1. Baseline Participant Characteristics

Exercise Control

Age (years) 4.0 ± 0.2 4.1 ± 0.2 Body mass index (kg/m2) 16.4 ± 2.1 16.1 ± 1.9 Alliteration (number of letters sounds correctly

identified/2 min) 2.3 ± 0.5 2.4 ± 0.5

Rhyming (number of rhymes correctly identified/2 min)

2.6 ± 0.4 2.4 ± 0.5

Picture naming (number of pictures named correctly/min)

18.2 ± 5.5 18.0 ± 5.1

Values are mean ± SEM. No difference between groups.

Teachers. Each classroom was staffed with 2 teachers (1 lead teacher and 1 assistant teacher). There were a total of 8 teachers (4 lead and 4 assistants), all of them women. The 4 lead teachers had a bachelor’s degree in early education with an average of 15 years of experience. The 4 assistant teachers had associate degrees in early education with an average of 10 years of experience.

Setting Head Start program. Within the Head Start pro-

gram, 2 sites totaling 4 classrooms participated in the study. The program sites were in the same urban city (just 1 mile apart) and managed through a partnership with a local university. Teachers followed the Head Start curriculum; teacher implementation and time spent on curriculum were identical in both preschools as measured by direct observation and teacher report. All available resources such as technology, educa- tional material, teacher training, were identical across classrooms. Both sites followed the same curriculum and were expected to monitor child progress toward outcomes as monitored by the Head Start Child Devel- opment and Early Learning Framework.19

Study Design A 2-group, quasi-experimental design with 1

preschool site participating in the PA intervention (1 preschool, 2 classrooms, N = 39 F, N = 25, M, N = 14) and a second site participating as the control site (1 preschool, 2 classrooms, N = 15, F, N = 12 F, M, N = 3) was used. The academic lessons taught using PA were designed to promote 60 minutes of PA in two, 30-minute periods during the school day. Activity lessons were delivered in the classroom. Each classroom was staffed with 2 teachers (1 lead teacher and 1 assistant teacher). Both teachers were part of the training session and took part in the leading of the academic lessons. Every effort was made through initial training and ongoing communication to remind teachers not to discuss the study with teachers at the other preschool location. At baseline, 4 and 8 months, early literacy skills (picture

naming, intraclass correlation coefficient [ICC] = 0.98, alliteration, ICC = 0.95, rhyming, ICC = 0.96) were obtained. Throughout the study, a member of the research team performed observations 5 days a week to ensure the academic lessons taught using PA were being administered correctly and to monitor fidelity.

Instruments Early literacy skills. Early literacy and language

skills were measured using the Early Literacy Indi- vidual Growth and Development Indicators (IGDI — Research and development of individual growth and development indicators for children between birth and age 8; Tech. Rep. No. 4, 1998). Picture Naming (mea- sure of oral language and vocabulary), Rhyming, and Alliteration (measures of phonological awareness) are commonly used as indicators of children’s language and literacy development in preschool programs.

Picture-naming individual growth and development indicator. Administration of the picture-naming indi- vidual growth and development indicator (PN IGDI) is completed by presenting children with color pic- tures (photographs or line drawings) of objects found in natural environments, including home (eg, cake, sink), classroom (eg, glue, book), and community (eg, rabbit, train). The children were told to name pictures as quickly as possible. The number of pic- tures named correctly in 1 minute was the child’s score. If the child did not respond to any given pic- ture within 3 seconds, the examiner gave a prompt by saying ‘‘What’s that?’’ or ‘‘Do you know what this is?’’ and allowed the child an additional 2 seconds to respond before moving to the next card. Items were selected from a set of approximately 120 pictured objects. Examiners were instructed to use 4 standard sample cards (to demonstrate the task and confirm the child’s understanding of the task), and then to admin- ister a randomly selected set of 1-50 cards. Hierarchical linear modeling (HLM) results centered at 66 months of age showed an average PN score of 19 with an average gain of .28 pictures per month for children liv- ing in low-income environments.20 Picture naming is sensitive to preschoolers’ growing expressive language skills, with significant correlations in typically devel- oping children (R = .63, p < .001), children enrolled in Head Start (R = .32, p < .05), and children with dis- abilities receiving services in early childhood special education classrooms (R = .48, p < .001).21

Rhyming individual growth and development indicator. Administration of the rhyming individual growth and development indicator (RH IGDI) is completed by presenting a child with a series of cards. Each card shows four pictures: at the top is a picture depicting the stimulus word (eg, bees) and under the stimulus picture is a row of 3 other pictures (eg, house, pants, cheese) with 1 correct and 2 incorrect responses.

For each card the examiner points to and says the name of each picture and tells the child to ‘‘point to the picture that sounds the same as the top picture.’’ After demonstration (2 standard cards) and practice items (4 randomly selected cards), the examiner shows a random selection of cards for 2 minutes. A child’s score is the number of correctly identified rhymes in 2 minutes. HLM centered at 53 months of age showed an average RH score of 6.5 with an average growth of .38 rhymes per month for children living in low- income families.21 Research has indicated moderate to high correlations between rhyming and picture naming IGDI (R = .46 to .63, p < .01) 21 and alliteration IGDI (R = .43).21

Alliteration individual growth and development indicator. Alliteration is similar to the other 2 IGDI’s in that it uses stimulus cards and the child’s score is the number correct during a timed administration. The alliteration individual growth and development indicator (AL IGDI) cards depict 4 pictures: at the top is a picture depicting the stimulus word (eg, cake) and under the stimulus picture is a row of 3 other pictures (eg, cat, sink, bear) with 1 correct and 2 incorrect responses. The child is told to ‘‘Look at the pictures and find the ones that start with the same sound.’’ For each card the examiner names all the pictures for the child. After demonstration (2 standard cards) and practice items (4 randomly selected cards), the examiner showed a random selection of cards for 2 minutes, counting the number correct in that time as the child’s score. HLM centered at 53 months of age showed an average AL score of 4.3 with an average growth of .25 alliterations per month for children living in low-income families.20 Alliteration correlates with other early literacy development (R = .75 to .79, p < .01).21

System for observing fitness instruction time. System for observing fitness instruction time provides a measure of student activity levels, lesson context, and teacher behavior22 using a Likert-type scale (eg, 1 = lying down, 2 = sitting, 3 = standing, 4 = walking, 5 = jogging/running). In other studies, SOFIT data have been shown to correlate significantly with average heart rate (R = .61) and TriTrac monitoring (a small devise that objective measures PA patters, R = .61).23

Interrater reliability. To calculate interrater relia- bility for the above-mentioned measures, 2 observers, independently but simultaneously, observed for approximately 33% of the classroom sessions. There were a total of 4 reviewers. Interobserver reliability estimates were calculated by dividing the number of agreements by the number of agreements plus disagreements, and multiplying the total by 100%. Interobserver agreement across sessions was 90%. Ratings were compared across research assistants for

reliability and percentage agreement was calculated. To control drift across time, reliability testing was con- ducted every 3 months.

Teacher survey of program. To gain additional information that would be helpful in guiding the overall design and implementation of the program for future studies, we asked teachers to complete a 10-item survey, which we adapted from the Child and Adolescent Trial for Cardiovascular Health (CATCH) Physical Education Observation Form,24 at the end of the study.

Statistical Analyses Early literacy skills. Child literacy skills were

assessed using 3 measures of early literacy skills. Picture-naming assessment of oral language and vocabulary, rhyming assessment of phonological awareness, and alliteration assessment of phonological awareness were analyzed using an adjusted t test,25

which accounted for the intraclass correlation, to assess change in these variables from baseline to 8 months. Change in picture naming, rhyming, and alliteration also was analyzed longitudinally, using a linear mixed model with an autoregressive type 1 covariance structure for the longitudinal measurements over time adjusting for sex.25

Fidelity of teacher implementation. Fidelity of teacher implementation of the PA lessons was measured using the SOFIT observation tool. SOFIT data were compared between the intervention and control classrooms using a mixed linear model adjusting for age and sex. The effects of teacher modeling on SOFIT scores were analyzed using analysis of variance (ANOVA).

Teacher satisfaction. Teacher satisfaction was mea- sured through a teacher survey. Data from the teacher survey were summarized descriptively, using means and standard deviations for continuous data and fre- quencies and percentages for categorical data. All quantitative analyses were done using SAS version 9.3 (SAS Institute, Inc., Cary, NC). The alpha level was set at .05 for all analyses.

Procedures PA program. The PA program was designed

by researchers with expertise in early childhood development and PA along with teachers and administrators at the Head Start program. To increase the likelihood of dissemination in other Head Start centers, the activities were designed to be administered by classroom teachers while being fun and engaging for preschool children. A variety of early literacy lessons were used in the areas of picture naming (assessment of expressive language development), rhyming, and alliteration (assessment of phonological awareness).

For example, a goal of a rhyming lesson was for children to find the rhymes within a particular poem or short story. The activity was designed to help children understand and identify rhyming words. During the lesson, children would march in place while the teacher repeated several lines of a poem and the child identified the words that rhymed. Depending on the words that rhymed, the children would either act out the words or perform a certain number of jumping jacks (or other movement) before moving on to the next 2 lines of the poem and repeating the sequence throughout the poem. Whereas these concepts were covered at both the intervention and control site, the primary difference was that the intervention site integrated these lessons into a PA rather than teach solely through large-group time, reading, or other classroom activities.

The program was designed to keep the children moving in moderate PA for 30 minutes 2 times per day (60 minutes daily). Sixty minutes per day of moderate intensity PA was chosen as it is recommended by the National Association for Sport and Physical Education (NASPE)26 and the National Association for the Education of Young Children (NAEYC).27 Despite these recommendations most preschool children do not meet these recommendations28 Therefore, integrating PA within the early literacy curriculum could be an effective way to increase daily PA. The program was administered inside or outside of the classroom, to music or without music. The goal was to make it fun and engaging for both the teachers and students. Teachers were free to choose the time each morning and afternoon that best fit into the day’s schedule but each teacher was required to administer a morning and afternoon session at a time when it was likely that most if not all students were in attendance (eg, after breakfast in the AM but before children are picked up by parents in PM). During the 8 months, daily direct observation by the investigators was used to ensure that the PA lessons were administered appropriately. Throughout the study, teachers in the intervention group were required to complete a daily activity log. To complete the log, teachers indicated in which PA lesson was used, the time of day they performed the activity lesson, the total number of minutes that each activity lasted, and estimate the intensity level at which they believed the children were performing (ie, light-, moderate-, or high-intensity levels). An e-mail was sent each week to the intervention teachers to remind them to complete the activity logs.

Teacher training. The principal investigators pro- vide training to the classroom teachers and assistants in each of the 2 intervention classrooms at a full-day in-service at the beginning of the school year. The goal of the in-service training was to develop compe- tency and strategies to deliver two, 30-minute periods

of moderate to vigorous intensity, physically active lessons per day. During the study a member of the research team was available in each classroom each day to observe and assist with the administering of the PA program. The first 2 weeks of the program was where most of the assistance in implementing the pro- gram occurred as the teachers learned the PA lessons. The primary area where research assistants helped the teachers in implementing the program was in know- ing how to do a particular activity movement such as jumping jacks or toe touches. After the technique was demonstrated, the research assistant would eval- uate how the teacher performed the activity with the children in the classroom. After the first 2 weeks, the teachers did not require any additional assistance, as the teachers were able to implement the PA lessons effectively.

Direct observation of PA lessons using SOFIT. Baseline SOFIT data were collected in both groups on each child during regular classroom activities. After baseline data were collected, PA levels of the children were assessed twice daily in the classrooms, once in the morning and once in the afternoon, in each group during both 30-minute sessions. Both groups performed the same learning activity during the same time of day. The only difference between the 2 groups was the intervention group had PA incorporated into the academic lesson. Three students from each classroom were randomly selected to be observed in both control and intervention sites to provide a measure of how active students were during classroom lessons. In 20-second intervals, for up to 20 minutes, the students’ PA intensity levels were estimated and recorded using the SOFIT rating scheme (ie, 1 = lying down to 5 = jogging or running). During observations, research assistants also indicated how often teachers participated in active lessons with their students by rating them on a 3-point scale (ie, none, somewhat, very active participation). This particular measure provided an indication of effective role modeling for active lessons.

RESULTS

Early Literacy Skills A linear mixed model was used to determine the

relative changes in early literacy skills. Picture nam- ing (pictures identified correctly per minute) signifi- cantly (p < .05) increased from baseline to 8 months in both exercise (30 ± 8%) and control (25 ± 6%) groups resulting in no between groups differences at 8 months, p > .05. Rhyming (pictures identified cor- rectly/2 minutes) significantly (p < .01) improved in the PA group from baseline to 8 months by 173 ± 12% compared with the controls (28 ± 8%), resulting in between group differences at 8 months, p < .01 (Figure 1). Higher scores for rhyming and alliteration

Figure 1. A Linear Mixed Model was Used. Values are Mean ± SEM. *p < .05 within Group compared with Baseline, **p < .01 within Group Compared with Baseline, # p < .01 between Groups within Period.

Figure 2. A Linear Mixed Model was Used. Values are Mean ± SEM. **p < .01 within Group compared with Baseline, # p < .01 between Groups within Period.

indicate greater early literacy skills and phonological awareness. Alliteration (letter sounds/2 minutes) sig- nificantly (p < .01) improved in the PA group from baseline to 8 months (52 ± 16%) compared to controls (13 ± 5%), resulting in between group differences at 8 months, p < .01 (Figure 2).

Correlation analyses indicated that the change in academic achievement from baseline to 8 months was significantly influenced by exposure to the activity lessons. As minutes of exposure to moderate to vigorous PA increased, the change in picture naming (R2 = .35, p < .05), alliteration (R2 = 0.38, p < .05), and rhyming (R2 = 0.42, p < .05), increased.

SOFIT During the study, observers conducted SOFIT

observations in all of the intervention and control

classrooms 5 times per week to determine student and teacher activity intensity levels.

A mixed linear model adjusting for age and sex showed that students at the intervention site performed significantly greater levels of PA in the classroom than students at the control site at 4 (intervention, 3.5 ± 0.4 versus control, 2.5 ± 0.4, p < .05) and 8 (intervention, 3.5 ± 0.4 versus control, 2.6 ± 0.5, p < .05) months; higher scores indicate higher activity intensity levels. Preschoolers at the control site were primarily sitting during academic lessons, whereas students in intervention site were primarily moving during the activity lessons.

The results indicated that adherence to the program was greater than 95%, meaning that students were obtaining all of the daily 60 minutes/day of recommended structured PA (Active Start: A Statement of Physical Activity Guidelines for Children Birth to Five Years, 2008) while being observed by the research staff.

During SOFIT observations, staff also indicated the level of participation by teachers during an active lesson. Overall teacher participation was related to SOFIT scores for students in the intervention schools but not the control schools. At baseline, teachers were not active at all (SOFIT mean score of zero) but increased to very active (SOFIT mean score = 3.7) at 4 months, which was maintained at 8 months (SOFIT mean score = 3.5). The analysis for the teacher modeling was performed using only the intervention schools because teacher participation had no effect on the activity level of students in the control schools.

Teacher satisfaction survey. At the end of the study, we gathered information from the teachers (N = 8) regarding the perception of the program and the likelihood that the program could be adopted into a preschool classroom (Table 2). In general, teachers reported that the program was easy to implement, children enjoyed the program, had a positive influence on the children’s learning and helped them focus better. Most encouraging, the teachers indicated that they would have their class participate in the PA program again.

DISCUSSION

To our knowledge, this is one of the first long- term studies to indicate that a teacher-directed PA program in a Head Start center serving African- American preschoolers is effective at increasing PA and improving measures of early literacy. The academic lesson plans taught using PA can be followed for at least 8 months with the potential for improving early literacy development. The study was well received by both the teachers and the students. The teachers indicated that they felt the program was

easy to administer, enjoyable, and made an impact on children’s learning in the classroom.

PA can have a significant influence on children’s early literacy skills. As expected, the PA levels in the classroom were increased in the intervention classrooms compared with the control classrooms, which is important because increased levels of PA are known to increase fitness and decrease risk factors for chronic disease in children.2,29-32 In the current study, the preschoolers were obtaining all of the daily 60 minutes/day of recommended structure PA26

through PA incorporated into curriculum lessons. Although we were unable to measure the PA outside of the classroom (ie, recess, playground), it is unlikely there were differences between the intervention and control sites because both schools followed identical schedules throughout each day. Instead, the impact of the PA program on early literacy most likely was attributed to the additional physical exercise that was scheduled in the classroom versus the PA that occurred as a result of outside play or recreational time at the control site.

Compared with the control group, academic achievement was significantly improved in the PA group. We found that alliteration and rhyming, both associated with greater early literacy skills and phonological awareness, were significantly improved in the PA group at 4 and 8 months compared with the control group. Improved literacy skill development in early childhood contributes to children’s long- term academic success. Children who lack the basic skills of phonological awareness, letter knowledge, and print awareness may have difficulty learning to read when they enter school. The children in the study were non-White and of low socioeconomic status, a group at greater risk for delays in developing early literacy skills and reduced ability to read.8,12

These children may not have access to before or after school tutoring that may enhance literacy skills. Therefore, developing strategies during the school day may be an effective strategy for improving early literacy.

We found that a PA program that can be incorporated within the preschool classroom may provide an important strategy to improve early literacy in minority preschool children, a group at high risk for delays in early literacy development. Potential reasons that PA may improve early literacy include improved attention to task, better long-term memory, enhanced ability of children to think and process information, and improved classroom behavior.8,33-36

Potential mechanisms for the association of PA and improvements in academic performance need further exploration in studies designed and powered for this purpose.

An important goal of the project was to be low-cost and low inconvenience, yet, fun for both

Table 2. Ratings for Selected Characteristics of Physical Activity Program Reported by Teachers (N = 8) Percent reported

Characteristic Strongly disagree Disagree Neutral Agree Strongly agree

Did you receive enough support/training? 0 0 0 40 60 The PA* program was easy to teach to children. 0 0 0 10 90 The PA program was easy to incorporate in the daily curriculum. 0 0 0 30 70 The children enjoyed the PA program. 0 0 0 0 100 The amount of time required for the PA program was appropriate for the classroom. 0 0 0 10 90 The PA program made a positive influence on student behavior. 0 0 0 30 70 The PA program helped my students release excess energy so they could concentrate. 0 0 0 20 80 The PA program had a positive impact on students’ learning. 0 0 0 60 40 Having PA as part of the daily schedule helped students focus on learning activities. 0 0 0 80 20 If given the opportunity, I would have my class participate in the PA program again. 0 0 0 0 100

teacher and child, increasing the likelihood that this program could be disseminated to other preschools. We also did not want it to take away from academic instruction time. We found that the program was well received by teachers and children. The teachers indicated the program was easy to teach to children, that the children enjoyed the program, felt that the children had better concentration, and that they would like to continue with the program in the future.

Limitations A limitation to the study was the small sample size.

Because an observer sat in the intervention classes every day for 8 months, it is possible (likely) that the very presence of the observer had an impact on use of the intervention and fidelity. The strength of this study was that both quantitative and qualitative methods were used to allow for a more thorough examination of program fidelity and implementation issues. Quantitative data regarding minutes of PA and number of lessons taught were collected weekly, which helped to determine if teachers were meeting the minimum prescription for the intervention. Weekly reporting also identified struggling teachers without delay. In this manner, assistance was provided before excessive time elapsed. Data also were collected to help determine challenges teachers faced implementing the intervention, allowing study personnel to help minimize barriers to increasing PA within their curriculum. It is possible that some adjustments to the training materials are needed to include demonstrations of activities given that in ‘‘real world’’ settings, the research team members would not be present to step in to help out the curriculum.

Conclusion In summary, the longer duration of the study

indicates that an academic program taught using PA

may be an important step in improving early literacy in children. One of the major advantages of the PA program is that it is a minimal intervention that can be easily disseminated, requiring minimal change to the current curriculum, few additional supplies (if any), and minimal cost to schools. Additionally, there was an overall favorable perception and acceptance for the PA program approach by teachers, students, and program administrators.

IMPLICATIONS FOR SCHOOL HEALTH

Schools may be able to address several health issues in conjunction with improving early literacy by delivering academic lessons using PA. Academic lessons using PA have been shown to reduce body weight and increase cardiovascular fitness in children37

which can lead to a reduction in diabetes and cardiovascular disease later in life. Also, PA has been identified as an effective way to increase blood flow and oxygen throughout the body, therefore improving the mind’s ability to receive new information. For young children at risk for delays in early literacy skills as well as other developmental areas, using PA as a means to embed learning opportunities throughout the day helps to create improved readiness for learning, by potentially improved attention to task and decreases in undesired classroom behavior,8,33-36 as children have opportunity to expend energy in a fun and appropriate way. Head Start is an ideal site to intervene with millions of children being cared for each day and this provides access to children and enables repeated exposure to health promotion interventions.38,39 This approach delivers academic lessons using PA; thus, there is no reduction in academic instruction time, a desirable feature for schools. The program requires minimal training costs and teacher preparation time. The program promoted the concept that PA can occur at many times and places without the need to report to a special place (gymnasium) and change into special clothes.

Human Subjects Approval Statement Prior to the start of the study, parents signed an

informed assent for their children to participate. The teachers signed an informed consent form prior to participation. The researchers’ university Institutional Review Board approved this study [ID: 46.110(7) institutional official Emily Krohn].

REFERENCES

1. Gettinger M, Stoiber K. Applying a response-to-intervention model for early literacy development in low-income children. Topics Early Child Spec Educ. 2008;27:198-213.

2. Kwak L, Kremers SP, Bergman P, Ruiz JR, Rizzo NS, Sjostrom M. Associations between physical activity, fitness, and academic achievement. J Pediatr. 2009;155(6):914-918.

3. Rasberry CN, Lee SM, Robin L, et al. The association between school-based physical activity, including physical education, and academic performance: a systematic review of the literature. Prev Med. 2011;52(Suppl):S10-S20.

4. Carlson SA, Fulton JE, Lee SM, et al. Physical education and academic achievement in elementary school: data from the Early Childhood Longitudinal Study. Am J Public Health. 2008;98(4):721-727.

5. Castelli DM, Hillman CH, Buck SM, Erwin HE. Physical fitness and academic achievement in third- and fifth-grade students. J Sport Exerc Psychol. 2007;29(2):239-252.

6. Christie J, Roskos K. Standards, science, and the role of play in early literacy education. In: Singer D, Golinkoff R, Hirsh- Pasek K, eds. Play = Learning: How Play Motivates and Enhances Children’s Cognitive and Social-emotional Growth. Oxford, UK: Oxford University Press; 2006:57-73.

7. Kibbe DL, Hackett J, Hurley M, et al. Ten years of TAKE 10!: integrating physical activity with academic concepts in elementary school classrooms. Prev Med. 2011;52(Suppl 1): S43-S50.

8. Miller P, Votruba-Drzal E. Early academic skills and childhood experiences across the urban-rural continuum. Early Child Res Q. 2013;28(2):234-248.

9. Reynolds AJ, Temple JA, Robertson DL, Mann EA. Long- term effects of an early childhood intervention on educational achievement and juvenile arrest: a 15-year follow-up of low- income children in public schools. JAMA. 2001;285(18):2339- 2346.

10. National Early Literacy Panel. Developing Early Literacy. Washington, DC: National Institute for Literacy; 2008. Available at: http://lincs.ed.gov/publications/pdf/NELPReport 09.pdf. Accessed November 29, 2015.

11. Snow CF, Burns MS, Griffin P. Preventing Reading Difficulties in Young Children. Washington, DC: National Academies Press; 1998.

12. Efrat M. The relationship between low-income and minority children’s physical activity and academic-related outcomes: a review of the literature. Health Educ Behav. 2011;38(5):441-451.

13. Basch CE. Physical activity and the achievement gap among urban minority youth. J Sch Health. 2011;81(10):626-634.

14. Coe DP, Pivarnik JM, Womack CJ, Reeves MJ, Malina RM. Effect of physical education and activity levels on academic achievement in children. Med Sci Sports Exerc. 2006;38(8):1515- 1519.

15. Wittberg RA, Northrup KL, Cottrell LA. Children’s aerobic fitness and academic achievement: a longitudinal examination of students during their fifth and seventh grade years. Am J Public Health. 2012;102(12):2303-2307.

16. Becker DR, McClelland MM, Loprinzi P, Trost SG. Physical activity, self-regulation, and early academic achievement in preschool children. Early Educ Dev. 2013;25(1):56-70.

17. Krafft CE, Schwarz NF, Chi L, et al. An 8-month random- ized controlled exercise trial alters brain activation during cognitive tasks in overweight children. Obesity. 2014;22(1): 232-242.

18. Singh AS, Mulder C, Twisk JWR, Van Mechelen W, Chinapaw MJM. Tracking of childhood overweight into adulthood: a systematic review of the literature. Obes Rev. 2008;9(5):474-488.

19. US Department of Health and Human Services (USDHHS). Head Start Child Development and Early Learning Framework. Washington, DC: USDHHS, Office of Head Start; 2010. Avail- able at: http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/teaching/ eecd/Assessment/Child%20Outcomes/HS_Revised_Child_ Outcomes_Framework(rev-Sept2011).pdf. Accessed November 29, 2015.

20. Missall C, McConnell C. Early literacy and language IGDIs for preschool-age children. In: Carta J, Greenwood C, Walker D, Buzhardt J, eds. Using IGDIs: Monitoring Progress and Improving Intervention for Infants and Young Children. Baltimore, MD: Brookes; 2010:181-201.

21. McConnell SR, Priest JS, Davis SD, McEvoy MA. Best practices in measuring growth and development for preschool children. In: Thomas A, Grimes J, eds. Best Practices in School Psychology. 4 ed., Vol. 2. Washington, DC: National Association of School Psychologists; 2002:1231-1246.

22. McKenzie TL, Sallis JF, Nader PR. SOFIT: system for observing fitness instruction time. J Teach Phys Educ. 1992;11(2):195-205.

23. Pope RP, Coleman KJ, Gonzalez BF, Heath EM. Validating SOFIT during physical education in a predominantly Hispanic community. Med Sci Sports Exerc. 2000;32(5):S328.

24. McKenzie TL, Sallis JF, Elder JP, et al. Physical activity levels and prompts in young children at recess: a two-year study of a bi-ethnic sample. Res Q Exerc Sport. 1997;68(3):195-202.

25. Donner A, Klar N. Design and Analysis of Cluster Randomized Trials in Health Research. London, UK: Arnold Publishers; 2000.

26. National Association for Sport and Physical Education (NASPE). Active Start: A Statement of Physical Activity Guidelines for Children Birth to Five Years. Reston, VA: NASPE; 2008.

27. National Association for the Education of Young Children (NAEYC). Accreditation Handbook. Washington, DC: NAEYC; 1998.

28. Sallis JF, Patterson TL, McKenzie TL, Nader PR. Family variables and physical activity in preschool children. J Dev Behav Pediatr. 1988;9(2):57-61.

29. Sassen B, Cornelissen VA, Kiers H, Wittink H, Kok G, Vanhees L. Physical fitness matters more than physical activity in controlling cardiovascular disease risk factors. Eur J Cardiovasc Prev Rehabil. 2009;16(6):677-683.

30. Cotman CW, Berchtold NC, Christie LA. Exercise builds brain health: key roles of growth factor cascades and inflammation. Trends Neurosci. 2007;30(9):464-472.

31. Steinberger J, Daniels SR. Obesity, insulin resistance, diabetes, and cardiovascular risk in children: an American Heart Association scientific statement from the Atherosclerosis, Hypertension, and Obesity in the Young Committee (Council on Cardiovascular Disease in the Young) and the Diabetes Committee (Council on Nutrition, Physical Activity, and Metabolism). Circulation. 2003;107(10):1448-1453.

32. Hu FB, Manson JE. Walking: the best medicine for diabetes? Arch Intern Med. 2003;163(12):1397-1398.

33. Schorr LB. Within Our Reach: Breaking the Cycle of Disadvantage. New York, NY: Doubleday; 1988.

34. Kozol JL. Savage Inequalities: Children in America’s Schools. Crown: New York, NY; 1991.

35. Gottlieb J, Alter M, Gottlieb BW, Wishner J. Special education in urban America: it’s not justifiable for many. J Spec Educ. 1994;2(7):453-465.

36. Davis CL, Tomporowski PD, Boyle CA, et al. Effects of aerobic exercise on overweight children’s cognitive functioning: a

randomized controlled trial. Res Q Exerc Sport. 2007;78(5): 510-519.

37. Donnelly JE, Greene JL, Gibson CA, et al. Physical activity across the curriculum (PAAC): a randomized controlled trial to promote physical activity and diminish overweight and obesity in elementary school children. Prev Med. 2009;49(4):336-341.

38. Kann L, Brener ND, Allensworth DD. Health education: results from the School Health Policies and Programs Study 2000. J Sch Health. 2001;71(7):266-278.

39. Goran MI, Reynolds KD, Lindquist CH. Role of physical activity in the prevention of obesity in children. Int J Obes Relat Metab Disord. 1999;23(Suppl 3):S18-S33.