healthcare
Article
Impact of an Interdisciplinary Educational Programme on
Students’ Physical Activity and Fitness
José Francisco Jiménez-Parra
Citation: Jiménez-Parra, J.F.;
Valero-Valenzuela, A. Impact of an
Interdisciplinary Educational
Programme on Students’ Physical
Activity and Fitness. Healthcare 2023,
11, 1256. https://doi.org/10.3390/
healthcare11091256
Academic Editor: Herbert Löllgen
Received: 13 February 2023
Revised: 23 April 2023
Accepted: 25 April 2023
Published: 27 April 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Healthcare 2023, 11, 1256. https://doi.org/10.3390/healthcare11091256
and Alfonso Valero-Valenzuela *
SAFE (Salud, Actividad Física y Educación) Research Group, Department of Physical Activity and Sport,
Faculty of Sport Sciences, University of Murcia, 30720 Murcia, Spain
* Correspondence: avalero@um.es
Abstract: Educational initiatives and actions are needed to provide students with skills to create
active habits and lifestyles in order to increase the physical activity and fitness levels of young people.
The main objective of this study was to analyse the effects of a classroom-based physical activity
and life skills programme on students’ physical activity and fitness levels. The sample consisted
of 65 students in the 6th grade of Primary Education, aged between 11 and 13 years (11.86 ± 0.53),
divided into a control group (CG) and an experimental group (EG) for convenience and accessibility.
This was a quasi-experimental, repeated measures, longitudinal cut-off research design. For 16 weeks,
an interdisciplinary educational programme based on a combination of classroom-based physical
activity and life skills was implemented. The results showed that the educational programme had
a positive effect on students’ physical activity levels during school hours, specifically on reducing
sedentary time (p < 0.001) and increasing light (p < 0.001) and moderate-to-vigorous (p < 0.001)
physical activity. Positive effects were also found on the variables of explosive strength (p < 0.05) and
aerobic capacity (p < 0.05) related to physical fitness. In conclusion, interdisciplinary educational
programmes based on the promotion of physical activity and life skills could contribute to the
development of responsible daily physical activity habits in students to facilitate their transfer to
other environments (social and family) outside school.
Keywords: active breaks; physically active lessons; active learning; teaching personal and social
responsibility; physical education; physical condition; health habits
1. Introduction
Nowadays, there is high concern among global bodies about meeting the third Sus-
tainable Development Goal (SDG) proposed by the United Nations for 2030, related to
ensuring the future health and well-being of young people [1]. Healthy lifestyles, physical
activity and fitness levels in this population are in decline [2], and the COVID-19 pandemic
further increased this trend [3]. The increasing prevalence of sedentary lifestyles, physical
inactivity and obesity in young people highlights that they are not acquiring the necessary
habits and skills to maintain a physically active lifestyle [2]. In this regard, the World Health
Organisation (WHO) recommends 60 min of moderate-to-vigorous intensity physical activ-
ity (MVPA) and 3 days of muscle and bone strengthening activities per week [4] for positive
outcomes on health-related variables such as physical fitness, cognitive development and
mental health [5].
In the absence of government strategies to address these concerns within schools, the
WHO proposed the Global Action Plan 2018–2030 for international policy systems to take
educational measures to provide guidance and support for regular physical activity (PA)
practice, with the goal of children growing up physically, psychologically, emotionally
and socially healthy [6]. Schools provide an ideal environment to provide multidimen-
sional health benefits to young people [7] through consistent education and exposure to
different types and levels of PA [2]. School-based PA, understood as the promotion of PA
https://www.mdpi.com/journal/healthcare
Healthcare 2023, 11, 1256 2 of 15

during school hours [8], appears to be an effective strategy to interrupt prolonged sitting
and physical inactivity, as well as to improve the MVPA and physical fitness of young
people [9–11].
Among the strategies used to promote school-based PA, we find Classroom-based
Physical Activity (CB-PA), understood as the incorporation of PA by teachers during school
teaching time [7]. It is considered one of the most appropriate strategies to reduce students’
sedentary time and physical inactivity during school time, as well as to increase their
cognitive involvement, academic performance and socio-emotional interaction [12–14]. In
relation to the motor domain, different studies found that CB-PA intervention programmes
had positive effects on PA levels [15,16] and physical fitness [17,18]. However, other studies
found no significant changes in PA and fitness levels [19], possibly due to the characteristics
of the intervention and the duration, frequency and intensity of PA applied during the
programme. Therefore, further research seems necessary on the characteristics of CB-PA
intervention programmes and the dose–response relationship of PA needed to achieve
improvements in the motor domain of young people.
CB-PA has evolved in recent years, coming to be incorporated into multicompo-
nent [20,21] and interdisciplinary PA programmes in combination with other teaching
methodologies such as the Teaching for Personal and Social Responsibility (TPSR) model [22]
to enhance multiple domains of student learning [23–25]. Multicomponent and interdisci-
plinary programmes are considered to be one of the promising approaches used to increase
the PA levels [26] and physical fitness of young people [27]. These school-based interven-
tions could help to maintain beneficial effects over time and transfer them to other contexts
if they are based on theoretical models of behavioural change [26]. Taking into account
that PA is influenced by multiple factors, the present educational programme is based on
multiple theoretical frameworks such as the social ecological model [28], self-determination
theory [29] and the theory of planned behaviour [30]. In this sense, the social ecological
model, the theory of self-determination and the theory of planned behaviour establish that
it is necessary to involve different agents of the school community (e.g., peers, teachers,
etc.) in educational PA programmes to promote autonomous motivational processes that
make it possible to achieve positive changes in health behaviour and in the intention to
practice PA [26,31].
Based on the above, the main objective of the present study was to analyse the effects of
a CB-PA and life skills programme on students’ PA and fitness levels. It was hypothesised
that the intervention programme based on CB-PA and life skills would have positive
physical consequences such as increased PA levels during school hours and improved
fitness levels.

2. Materials and Methods

2.1. Design
In this study, a quasi-experimental design with repeated measures and longitudinal
cut-off was carried out, as the pre-test and post-test results of a group that received a treat-
ment under evaluation were compared with a group that did not receive any treatment in a
time interval and the sample was not randomised [32]. The design of the study can be seen
in the CONSORT flow diagram (Figure 1). In addition, the study presented a quantitative
methodological approach, since the levels of PA and fitness of the participating groups
were quantified and analysed by means of specific measures and tests at the beginning
and end of the programme. The protocol of the educational intervention programme,
called ACTIVE VALUES, has been detailed and published previously [22], following the
Template for Intervention Description and Replication (TIDieR) [33] and the guidelines
of the Transparent Reporting of Evaluation with Nonrandomised Designs (TREND) [34].
The protocol and the intervention study were approved by the Ethics Committee of the
University of Murcia (3207/2021) and developed in accordance with the Declaration of
Helsinki.
Healthcare 2023, 11, 1256 3 of 15

Figure 1. CONSORT flow diagram.

2.2. Sample
The sample in the present study was selected by convenience and accessibility, using
four natural groups from the 6th grade of primary education. The sample was divided into
an experimental group (EG) (N = 31; 15 girls; 11.87 ± 0.56 years) and a control group (CG)
(N = 34; 17 girls; 11.85 ± 0.50 years), with ages between 11 and 13 years (11.86 ± 0.53 years).
The participants belonged to two public schools in the region of Murcia (Spain), with a
medium-low socioeconomic level.
To minimise experimental and investigator bias, the principal investigator was not
involved in the placement and collection of the devices, nor in the implementation of the
CB-PA + TPSR-based programme.
Healthcare 2023, 11, 1256 4 of 15

Eligibility Criteria
The inclusion/exclusion criteria were:
a. Students enrolled in the sixth year of elementary education.
b. Attend school more than 80% of the time.
c. Complete the measurements (PA and fitness) in the pre-test and post-test.
d. Not having been diagnosed with special educational needs.
e. No partial or chronic problems (e.g., heart disease, diabetes, asthma, injuries, etc.)
that could prevent participation in data collection or programme activities.

2.3. Instruments
The following variables were measured to assess the well-being and physical mastery
of the participants: (1) PA levels and (2) fitness.

2.3.1. Levels of PA
The measurement of PA levels was performed with ActiGraph GT3X and wGTX-BT
accelerometers (Actigraph, Pensacola, FL, USA), since they have triaxial measurement
of acceleration [35] and have demonstrated validity and reliability for measuring this
variable in the study population [36–40]. These devices were programmed with 60 Hz
frequency (ActiGraph wGTX-BT) and a one-second epoch (ActiGraph GT3x) to collect
data every day of the week during school hours (9:00 a.m. to 14:00 p.m.; school-based
PA). Data were recorded in the week prior to the start of the intervention (pre-test, week
0) and in the last week of the intervention programme (week 16). Taking into account
the recommendations to place the accelerometers in areas close to the centre of body
mass [41–43], the devices were placed on the students’ right hips using an elastic belt [44].
In addition, the participants recorded, in a weekly diary, the activities they performed
during recess and physical education [16].
Data were downloaded and analysed using ActiLife software (ActiGraph, version
6.8.0, Pensacola, FL, USA). Data recording was considered valid when it collected equal
to or greater than four hours per day for four days per week [16]. The cut-off points
established by Evenson et al. [45] in children and young people were selected to analyse the
time of PA measured by the accelerometers, using the unit of measurement counts ×min−1 :
(a) sedentary (0–100), (b) light (100–2295), (c) moderate (2296–4012), and (d) vigorous
(4013>). PA levels were calculated per minute/school day by dividing each PA level by
the valid number of days recorded [18]. MVPA was obtained by adding up the minutes of
moderate and vigorous PA [46]. To assess the impact of the programme, different moments
throughout the school day and week were evaluated [16]: (a) school/curricular time;
(b) recess or lunchtime; and (c) Physical Education lessons.

2.3.2. Fitness
To assess physical condition, anthropometry and basic physical capacities, the students
were measured before (pre-test) and after (post-test) the intervention. The fitness assessment
protocol followed the approach used in the HELENA (Healthy Lifestyle in Europe by
Nutrition in Adolescence) study [47]. Three evaluators at the same time, including the
Physical Education teacher, assessed these variables:
• Anthropometry and body composition
The Seca® 876 scale and a Seca® 220 telescopic height measuring instrument (Seca,
Hamburg, Germany) were used to measure the weight and height of the participants. In the
weight measurement, students were asked to wear light clothing and to remove footwear
and other accessories that could influence the assessment. In the height measurement,
students were asked to stand barefoot, upright and immobile next to a wall, with their heels
together, arms extended along the body and looking straight ahead in sagittal position.
Each parameter was measured twice to confirm the mean value of the measurement [48].
Healthcare 2023, 11, 1256 5 of 15

The body composition of the participants was calculated using the body mass index
(BMI) formula: weight difference by height squared (kg/m2 ). The international BMI cut-
off points for classifying children according to sex and age were [49]: (a) normo-weight,
children with BMI values corresponding to an adult BMI below 25; (b) overweight, children
with BMI values corresponding to an adult BMI between 25 and 30; and (c) obese, children
with BMI values corresponding to an adult BMI above 30 [50].
• Fitness level
The ALPHA-Fitness battery was used to measure students’ fitness levels [48], with
the addition of a test from the EUROFIT battery [51] to assess flexibility. To ensure student
safety, American College of Sports Medicine guidelines [52] and the established protocol
for these test batteries [47,48,51] were followed. In addition, participants were briefed on
the protocol to ensure greater success in the data collection process [19]. Data collection
was conducted in the school gymnasium to maximise student safety and avoid falls due to
slips [48]. The cut-off points for the physical fitness tests were obtained from the European
HELENA [47] and EUROFIT [53] studies for boys and girls aged 11–13 years. The tests
were evaluated following the order of the HELENA protocol [47]:
1. Lower-limb explosive strength: the long jump test with feet together was used to
measure the explosive strength of the lower body. Students were instructed to stand
behind the jump line with their feet shoulder-width apart and perform a horizontal
jump to reach the maximum possible distance, which was recorded in centimetres.
The students performed two jumps, with 30 s of recovery between jumps to minimise
the effect of fatigue [19]. The jump with the greatest distance was recorded. A Model
74-Y100M tape measure (CST/Berger, Chicago, IL, USA) was used to measure the
distance of the jump.
2. Speed/agility: the 4 × 10 meters speed test was used to evaluate the coordination,
agility and speed of the participants. The students had to run and turn at maximum
speed for four repetitions of 10 m distance. Each participant had two attempts with a
60-s rest between attempts. The best result obtained was recorded. The evaluators
measured the test in seconds with a hand-held stopwatch (HS-80TW-1EF, Casio,
Tokyo, Japan).
3. Flexibility: the sit-and-reach test of the EUROFIT battery [51] was used to assess
students’ flexibility [54,55]. Participants had to sit barefoot in front of a box (Baseline
Sit n’ Reach Trunk Flexibility Box, Fabrication Enterprises Inc, Elmsford, New York,
NY, USA) with their legs extended and with the soles of their feet in full contact with
the wall of the box. After that, they flexed their trunk forward without bending their
legs and extending their arms to try to carry the ruler as far as possible. The highest
position that the students reached and were able to maintain for at least two seconds
was recorded. The greatest distance reached, in centimetres and millimetres, of the
two attempts made by each participant was recorded.
4. Aerobic capacity: the 20 m out-and-back running test was used to assess aerobic
capacity [56]. Participants had to run between two lines located 20 m apart and make
directional changes at the pace set by audio signals that were emitted by a portable
audio system (Behringer EPA40, Burgebrach, Germany) and USB player (Hayabusa,
Toshiba, Tokyo, Japan) that had the test protocol [19]. The test started at a signal
speed of 8.5 km/h, which increased by 0.5 km/h every minute. The participants were
stopped when they were not able to keep up with the audio signal (fatigue) or to
reach one of the lines for the second consecutive time. This test had only one attempt
and the last half-stage completed was recorded.

2.4. Procedures
An educational programme called “ACTIVE VALUES” was designed and imple-
mented based on the theoretical frameworks of the social ecological model, the self-
determination theory and the theory of planned behaviour, as well as effective strategies to
Healthcare 2023, 11, 1256 6 of 15

promote life skills and increase PA during school hours. Following the social ecological
model and adopting an interdisciplinary approach to school, as previously proposed by
other studies [26], the “ACTIVE VALUES” educational programme aimed to empower and
support students to create their own responsible and autonomous habits in order to be
physically active and increase their PA levels.
Based on the self-determination theory and the theory of planned behaviour, teachers
who applied the interdisciplinary educational programme followed a specific training
process composed of two stages [57]: (a) Basic Training, a stage in which an initial 15 h
theoretical–practical course was carried out to provide the participating teachers with
sufficient resources and strategies to further support needs, promote life skills and increase
students’ PA levels; and (b) Continuous Professional Development, a stage in which the
principal researcher followed up the intervention (once a month) through specific strategies
such as training seminars, feedback and resolution of doubts [58].
The continuous professional development was complemented with a process of im-
plementation fidelity [59] based on the observational analysis of the sessions implemented
by the teachers during the intervention programme [60]. For this purpose, two sessions
were recorded every 2–3 weeks and analysed by the research group using the tool for
evaluating responsibility-based education and PA in the classroom [23,24]. Following the
observational analysis, feedback reports were written by the principal investigator and
shared with the teachers to provide support and guidance during the intervention [58]. In
addition, teachers were invited to evaluate their own performance in implementing the
educational programme after each school day to reflect on the strengths and weaknesses
they were encountering in the intervention [61]. All these aspects were pooled in the
training meetings/seminars held by the principal investigator with the EG teachers (once a
month) to ensure greater adherence and fidelity to the intervention programme.
The intervention programme was applied for four months (60–90 min sessions;
2–3 times per day) in different subject areas, following the curriculum of the educational
centres and the content of the Spanish educational legislation [62]. The interdisciplinary
educational programme consisted of the application of different strategies to foster CB-PA,
support needs and life skills in students, following proposals made in previous stud-
ies [22,24–26]. The teachers incorporated CB-PA through the methods proposed by Watson
et al. [7]: (a) PA of short duration and any level of intensity (mainly MVPA) to break with
the teaching dynamics, as a time-out from homework and to reduce sedentary lifestyles
and physical inactivity of students (active breaks); and (b) PA directly related to curricular
content (e.g., counting in one school subject) (physically active learning). Support needs
and life skills were incorporated through the flexible application of the fundamental TPSR
strategies for the levels of responsibility [63]: (1) respect for the rights and feelings of others;
(2) participation and effort; (3) personal autonomy; (4) helping others and leadership;
and (5) transfer to life outside school. The levels were approached in a progressive and
interactive manner [64] to meet support needs and develop life skills related to habits of
personal and social responsibility. The transfer level was used to teach and give enough
tools to students to put what they had learned outside the school context (e.g., taking an
active rest when sitting for a long time doing homework, doing PA autonomously, helping
and encouraging family members to increase movement at home) into practice.
The intervention programme sessions followed the TPSR session structure [63], adapted
to the multidisciplinary context [22]: (1) Awareness-raising—teachers welcomed students
and presented the goals to be achieved in the session related to PA and life skills (setting
expectations); (2) Active responsibility—teachers set comprehensive tasks to promote CB-
PA, support needs and life skills (examples of tasks can be seen in Table 1), as other studies
have previously done [24,25]; (3) Group meeting—teachers proposed a discussion through
an open question for students to reflect and share feelings, perceptions and opinions about
their learning; and (4) Self and co-evaluation—teachers allowed students to evaluate their
own, their classmates and the teacher’s performance using the thumb technique.
Healthcare 2023, 11, 1256 7 of 15

Table 1. Pedagogical tasks carried out during the intervention programme.

Classroom-Based
Example of Tasks
Physical Activity
High intensity physical activity routine with 20” of movement
(e.g., getting in and out of the chair + multi jumps + skipping) and
10” of rest (e.g., military march) (×3)
Active Breaks
Dance activities through the use of interactive videos (e.g.,
just dance)
Leaving the classroom, running around the schoolyard and
returning to class
Exercises for joint mobility, coordination and stretching
Solving mathematical problems by physical motion
(mathematics)
Physically Active Learning Represent and classify animals with movement according to their
diet (Natural Sciences)
Socio-dramatic representation of life skills related to levels 1 and 4
of the TPSR (Spanish Language)
Students create a dance (TPSR levels 2 and 3) to learn body parts
in the English language
Note: TPSR = Teaching Personal and Social Responsibility.

2.5. Statistics
The study variables were characterised through descriptive statistics of frequency and
percentage. The Lilliefors and Shapiro–Wilk statistical tests were used to test the normality
of the data, since the study sample had less than 50 participants in each group [65]. The
analysis showed a non-normal distribution of the data (p < 0.05); therefore, the participant
groups were compared (intergroup analysis; control vs. experimental) using the Mann–
Whitney U statistical test comparing the variables between the control and experimental
groups. Subsequently, the Wilcoxon statistical test was used to evaluate the evolution
of each group (intragroup analysis) before and after the intervention (pre-test and post-
test). Finally, the effect size was calculated to check the magnitude of the intergroup and
intragroup differences, following the effect size values proposed by Cohen [66]: small
(d = 0.20), medium (d = 0.50) and large (d = 0.80). Statistical analyses were performed with
the statistical packages IBM SPSS 25.0 and G*Power 3.1.9.7.

3. Results
3.1. PA Levels
Table 2 shows the means and standard deviations of the PA levels of the groups
participating in the study (CG and EG) as a function of the time of the school day and
the intervention time (pre-post). The p-values obtained with the Mann–Whitney U-test
revealed no significant differences (p < 0.05) between groups in the pre-test. Therefore, the
CG and EG had a similar level before the start of the intervention programme.
Regarding pre–post intragroup differences, the Wilcoxon rank test revealed that CG
significantly increased sedentary time (p = 0.016) during Physical Education classes and
significantly reduced moderate PA (p = 0.004), vigorous (p = 0.041) and MVPA (p = 0.012)
in Physical Education time. The EG significantly reduced the total sedentary time during
school hours (p = 0.000), recess (p = 0.018) and Physical Education classes (p = 0.022), while
it significantly increased the levels of (a) light PA during school hours (p = 0.036), at recess
(p = 0.025) and Physical Education (p = 0.030); (b) moderate PA at school time (p = 0.000);
(c) vigorous PA at school time (p = 0.000) and Physical Education (p = 0.012); and (d) MVPA
at school time (p = 0.000), at recess (p = 0.035) and Physical Education (p = 0.033).
Healthcare 2023, 11, 1256 8 of 15

Table 2. Differences in PA levels between before and the last week of the intervention programme
according to group.

Pre-Test Post-Test Pre–Post Intra-Group Test

(Week before the Start of (Last Week of Intervention—Week 16) Differences
Intervention—Week 0)
Control Experimental Control Experimental Control Experimental
School PA
Activity Levels Mean ± SD Mean ± SD p d Mean ± SD Mean ± SD p d p d p d
(Time)
Sedentary
237.0 ± 12.97 237.5 ± 15.21 0.773 0.04 237.6 ± 14.27 220.0 ± 18.23 0.000 ** 1.07 0.305 0.04 0.000 ** 1.07
(min)
Light
51.2 ± 8.54 50.8 ± 11.02 0.942 0.03 50.9 ± 9.03 56.4 ± 11.15 0.037 * 0.55 0.688 0.03 0.036 * 0.51
(min)
School Moderate
day 7.0 ± 2.84 7.1 ± 2.88 0.906 0.03 6.9 ± 3.13 15.2 ± 5.41 0.000 ** 1.88 0.416 0.04 0.000 ** 1.86
(min)
Vigorous
4.8 ± 2.14 4.6 ± 2.28 0.550 0.10 4.7 ± 2.60 9.2 ± 3.20 0.000 ** 1.54 0.166 0.05 0.000 ** 1.66
(min)
MVPA 11.9 ± 4.93 11.7 ± 5.01 0.803 0.04 11.6 ± 5.67 24.0 ± 8.42 0.000 ** 1.73 0.252 0.06 0.000 ** 1.78
(min)
Sedentary
17.5 ± 4.24 17.6 ± 4.41 0.813 0.01 17.6 ± 4.34 16.1 ± 4.31 0.133 0.37 0.297 0.04 0.018 * 0.36
(min)
Light
7.2 ± 2.15 7.3 ± 2.20 0.916 0.05 7.1 ± 2.16 8.1 ± 2.19 0.042 * 0.48 0.297 0.04 0.025 * 0.39
(min)
Recess Moderate 3.1 ± 1.16 2.9 ± 1.27 0.423 0.15 3.1 ± 1.25 3.3 ± 1.12 0.382 0.19 0.467 0.05 0.084 0.28
(min)
Vigorous
2.2 ± 1.10 2.1 ± 1.20 0.559 0.06 2.1 ± 1.05 2.4 ± 1.15 0.358 0.26 0.748 0.05 0.073 0.26
(min)
MVPA 5.3 ± 2.23 5.1 ± 2.45 0.454 0.11 5.2 ± 2.28 5.8 ± 2.34 0.279 0.25 0.452 0.05 0.035 * 0.30
(min)
Sedentary
31.4 ± 4.53 31.9 ± 5.32 0.773 0.10 31.8 ± 4.83 30.5 ± 4.47 0.303 0.27 0.016 * 0.10 0.022 * 0.27
(min)
Light
21.5 ± 2.41 21.1 ± 3.30 0.793 0.12 21.3 ± 2.42 22.2 ± 2.34 0.134 0.37 0.071 0.06 0.030 * 0.37
(min)
Physical Moderate
Education 4.1 ± 1.33 4.1 ± 1.08 0.618 0.01 3.9 ± 1.47 4.3 ± 1.33 0.205 0.28 0.004 ** 0.11 0.150 0.21
(min)
Vigorous
3.1 ± 1.19 2.6 ± 1.13 0.145 0.39 2.9 ± 1.34 2.9 ± 1.12 0.758 0.01 0.041 * 0.09 0.012 * 0.29
(min)
MVPA 7.2 ± 2.50 6.7 ± 2.13 0.586 0.20 6.9 ± 2.80 7.3 ± 2.38 0.393 0.15 0.012 * 0.10 0.033 * 0.26
(min)
Note: * p < 0.05; ** p < 0.01; SD = Standard deviation; d = effect size (Cohen); PA = Physical Activity;
MVPA = Moderate-to-Vigorous Physical Activity.

In the last week of intervention (post-test), the Mann–Whitney U-test revealed statisti-
cally significant intergroup differences in favour of the EG in light (p = 0.036), moderate
(p = 0.000), vigorous (p = 0.000) and MVPA (p = 0.000) levels during weekly school hours.
In addition, significant differences were found in favour of this group for the variable of
light PA during weekly recess time (p = 0.042). The variable weekly sedentary time during
school hours (p = 0.000) showed significant differences in favour of the CG.

3.2. Fitness Level

Table 3 shows the means and standard deviations of the CG and EG fitness levels
at baseline and at the end of the intervention. As with the PA levels, the Mann–Whitney
U-test revealed no significant differences (p < 0.05) in the pre-test, so there was homogeneity
between groups in the fitness levels at the start of the intervention programme.
The Wilcoxon test showed statistically significant intra-group differences in the EG, as
they improved their levels of explosive strength (p = 0.000), speed/agility (p = 0.000) and
aerobic capacity (p = 0.000). In the post-test, the Mann–Whitney U-test showed statistically
significant intergroup differences in favour of the EG in the fitness levels of explosive
strength (p = 0.028) and aerobic capacity (p = 0.038).
Healthcare 2023, 11, 1256 9 of 15

Table 3. Differences in fitness level before and after the intervention programme according to group.

Pre-Test Post-Test Pre–Post Intra-Group Test

Differences
Control Experimental Control Experimental Control Experimental

Variable Factors/ Mean ± SD Mean ± SD p d Mean ± SD Mean ± SD p d p d p d

Dimensions
BMI 21.95 ± 1.42 22.00 ± 2.07 0.793 0.03 22.02 ± 1.44 21.93 ± 1.93 0.655 0.05 0.054 0.05 0.125 0.03
(kg/m2 )
Explosive
strength 118.47 ± 11.62 116.87 ± 13.49 0.650 0.13 119.03 ± 11.79 125.94 ± 12.90 0.028 * 0.56 0.348 0.05 0.000 ** 0.69
(cm)
Fitness Speed/agility
14.21 ± 0.95 14.36 ± 1.05 0.490 0.15 14.27 ± 1.03 14.12 ± 1.00 0.577 0.15 0.061 0.06 0.000 ** 0.23
(s)
Flexibility
25.29 ± 3.17 24.33 ± 3.40 0.273 0.29 25.17 ± 3.24 24.45 ± 3.22 0.382 0.22 0.109 0.04 0.134 0.04
(cm)
Aerobic
capacity/
2.46 ± 1.36 2.37 ± 1.30 0.771 0.07 2.38 ± 1.40 3.19 ± 1.50 0.038 * 0.56 0.096 0.10 0.000 ** 0.58
endurance
(stages)
Note: * p < 0.05; ** p < 0.01; SD = Standard deviation; d = effect size (Cohen); BMI = Body Mass Index.

4. Discussion
Regarding the first part of the proposed objective, to analyse the effects of combining
the CB-PA and life skills on students’ PA levels, the results of the study reflected that the
EG obtained improvements in all levels of PA throughout the school day, decreasing the
sedentary time and increasing the levels of light, moderate and vigorous PA and MVPA,
while in the CG there was no change in this regard. Previous studies [15,16,67–69] which
focused on analysing the PA levels of primary school students during school hours using
accelerometers reported similar results. Specifically, Muñoz-Parreño et al. [16] reported
increases in the MVPA in total school time. Different works that included CB-PA reported
changes in the MVPA level throughout the school day where the active breaks were
taught [69]. Other investigations, such as those by Donnelly et al. [68], Goh et al. [15] or
Van de Berg et al. [70], reported a higher number of MVPA during school hours, although
without specifying at what times of the school day.
On the other hand, there are studies such as the ones by Watson et al. [71] or Martin
and Murtagh [72] which did not find differences between groups in MVPA levels during
school hours, stating that this could be due to the fact that children compensated for PA by
being less active the rest of the school day [73], and in the case of the study by Martin and
Murtagh [72], the fact that the sample size was small or there was great variability. In the
current study, it is interesting to highlight that although the changes occurred within the
group which received the intervention, these changes were not confirmed when comparing
the CG with the EG, so some of the arguments indicated by the authors previously reviewed,
such as sample size, should be taken into account.
As for the recess time, only one study has been found related to this variable [16],
reporting increases in the MVPA, agreeing with the results obtained in this study. In
addition, higher levels of light PA and a decrease in sedentary activity were reported in the
intervention group over time.
Focusing attention on the possible changes obtained in PE or other curricular subjects
in which CB-PA has been included, the study by Muñoz et al. [16] did not show any kind
of change in the different variables related to PA (sedentary, light, moderate, vigorous or
MVPA. These outcomes were in line with those obtained in the present study, where no
significant differences were found between PA levels recorded by the intervention group
compared to the control group. On the other hand, in the study by Riley et al. [69], where
AB were used during mathematics lesson and PA levels were measured, changes in MVPA
and sedentary time were reported. The same thing was presented by Norris et al. [67],
who report changes in PA levels during classes (in which the content of the curriculum
was taught). Therefore, the use of CB-PA could have a positive consequence in different
curricular subjects but not in PE, which by its own character is a subject that contains PA.
Healthcare 2023, 11, 1256 10 of 15

Regarding the second part of the proposed objective, to analyse the effects of com-
bining the CB-PA and life skills on students’ fitness levels, no changes in the BMI of the
students were obtained, as was the case with Drummy et al. [74], who applied three active
breaks of 5 min a day for 12 weeks in primary school students. On the other hand, other
works that have also considered this variable have reported differences when compared to
the control group, with small increases in BMI, as is the case for Donnelly et al. [68], with
active breaks in the classroom and 90 min of PA per week, and for Li et al. [75] with 100 min
of PA per week.
In the present research, improvements in explosive strength, speed/agility and aerobic
capacity were obtained at the level of the EG over time, as well as when comparing the
results with the CG (except for speed/agility). Contrasting these results with those of other
studies focused on students in the primary school stage, we found the work by Mendoza-
Muñoz et al. [17], which after applying a 4-week programme of active breaks reported
improvements in the cardiorespiratory capacity and speed/agility of their students. Only
in one other study, although in this case focused on the secondary school stage where active
classes with bike tables were used, were improvements obtained in physical condition at
the cardiovascular level [76].
The rest of the studies that have assessed physical condition have not reported im-
provements at the level of aerobic capacity, as is the case for Van de Berg [70], who applied
a programme of active breaks of 10 min a day for 9 weeks, or in González-Fernández
et al. [19], studying secondary school students with two breaks a day of approximately
10 min each for 8 weeks. As previous studies have shown [7,9,77], the amount, frequency,
duration and intensity (dose–response relationship) of PA in intervention programmes
based on CB-PA are factors that can directly influence the achievement of positive and
significant results in health-related variables such as PA level and physical fitness.
Two strengths of this study should be highlighted; firstly, the consideration of both
the variables of PA levels and fitness at the same time. This is because intensity influences
the results obtained and is essential for improvements in physical condition, as suggested
by González-Fernández et al. [19]. There are several studies mentioned in this paper that
have analysed one or the other, but not both at the same time. Indeed, very few studies
found have evaluated both variables in the primary stage [68,70,74]. Secondly, it should be
noted that in this study an interdisciplinary educational programme was used, whereby
the CB-PA were combined with life skills (TPSR) to create responsible and autonomous
habits of PA practice in students, and transfer them to different contexts of life (social
and family). Taking into consideration the social ecological model, self-determination and
planned behaviour theories, this interdisciplinary educational programme could be more
effective, contributing to students acquiring the knowledge and skills necessary to create
and maintain healthy lifestyle habits through the self-regulation of their own practice of PA.
Despite the study’s strengths, it also has several limitations. One of them is the type of
research design (quasi-experimental), since the sample was not randomised and, therefore,
the representativeness of the school population cannot be ensured. Another limitation
is the small number of participants, which could have influenced the results in addition
to not providing sufficient statistical robustness to perform multivariate tests [72,78]. An
additional limitation is the measurement of PA levels during school hours, as the students
did not carry the accelerometers outside of the school, which made it impossible to control
extracurricular activities and verify the effects of the programme on the active behaviour of
the students in their daily lives.
For these reasons, future studies should be aimed at designing randomised clinical
trials with a larger number of participants in which educational programmes based on
the combination of CB-PA and life skills are implemented to improve the quality of life
of young people and make new generations aware of the importance of creating and
maintaining responsible and autonomous habits of health and PA. In addition, prospective
research should consider longitudinal interventions in which PA levels are measured
outside of school hours to test the effects of the intervention programme on achieving
Healthcare 2023, 11, 1256 11 of 15

WHO recommendations [4] and transferring healthy habits to different contexts of life
(social and family). Lastly, future research could evaluate other variables related to life
skills (e.g., problem solving, interpersonal relationships, etc.) and health (e.g., body folds,
adiposity, heart rate, etc.), as well as the maintenance of these variables after completing
the intervention by performing a test–retest.

5. Conclusions
The study results suggest that applying a programme based on CB-PA and life skills
for 16 weeks had a positive effect on the levels of PA during school hours and the fitness of
the students. These findings show the importance of implementing interdisciplinary educa-
tional programmes based on active methodologies to achieve the multilateral development
of young people and improve their quality of life and motor performance. In addition, this
study stands out for providing the reference PA levels to carry out a monitoring plan and
achieve improvements in the physical condition of the students, thus contributing to locate
the dose–response relationship of CB-PA in future studies. Some practical applications
of the findings could include pedagogical tasks related to life skills during the curricular
lessons that might create more adherence to PA, such as students creating a dance to learn
body parts in a foreign language, as at the same time they are encouraging participation
and autonomy life skills.
However, it is suggested that future research proposes longitudinal experimental
designs (e.g., one academic year) with a follow-up and fidelity plan for the intervention
to analyse with greater precision the evolution and transfer of students’ active behaviour
to different environments (school, social and family), and moments (before, during and
after the intervention). In this way, studies could evaluate the levels of PA outside the
school environment to deepen the holistic understanding of the effects of the programme in
relation to the achievement of the recommendations of daily PA proposed by the WHO and
the third of the Sustainable Development Goals adopted by all United Nations Member
States. In addition, it is suggested that future studies analyse the characteristics of the
intervention such as the type (e.g., active breaks, physically active learning, gestures, etc.),
frequency, duration and intensity of the CB-PA, as well as the strategies for the promotion
of life skills (e.g., levels of responsibility, autonomy, transfer, empowerment, etc.) to better
understand the effects of the programme on different learning domains.

Author Contributions: Conceptualisation, J.F.J.-P. and A.V.-V.; methodology, J.F.J.-P.; software, A.V.-V.;
validation, J.F.J.-P. and A.V.-V.; formal analysis, J.F.J.-P. and A.V.-V.; investigation, J.F.J.-P.; resources,
A.V.-V.; data curation, J.F.J.-P. and A.V.-V.; writing—original draft preparation, J.F.J.-P.; writing—
review and editing, A.V.-V.; visualisation, J.F.J.-P. and A.V.-V.; supervision, A.V.-V.; project administra-
tion, J.F.J.-P. All authors have read and agreed to the published version of the manuscript.
Funding: The first author of this study obtained funding through the university teacher training
program (Formación del Profesorado Universitario) of the Spanish Ministry of Universities (grant
code: FPU19/04318).
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and after obtaining the approval of the Ethics Committee of the University of Murcia
(3207/2021).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study.
Data Availability Statement: Not applicable.
Acknowledgments: We thank the elementary schools for their willingness to participate in this
research.
Conflicts of Interest: The authors declare no conflict of interest.
Healthcare 2023, 11, 1256 12 of 15

References
1. Santos, A.C.; Willumsen, J.; Meheus, F.; Ilbawi, A.; Bull, F.C. The cost of inaction on physical inactivity to public health-care
systems: A population-attributable fraction analysis. Lancet Glob. Health 2023, 11, e32–e39. [CrossRef]
2. Till, K.; Bruce, A.; Green, T.; Morris, S.J.; Boret, S.; Bishop, C.J. Strength and conditioning in schools: A strategy to optimise health,
fitness and physical activity in youths. Br. J. Sports Med. 2022, 56, 479–480. [CrossRef]
3. Jurak, G.; Morrison, S.A.; Kovač, M.; Leskošek, B.; Sember, V.; Strel, J.; Starc, G. A COVID-19 crisis in child physical fitness:
Creating a barometric tool of public health engagement for the Republic of Slovenia. Front. Public Health 2021, 9, 644235.
[CrossRef]
4. World Health Organization. Global Recommendations on Physical Activity for Health; World Health Organization: Geneva, Switzer-
land, 2020.
5. Bull, F.C.; Al-Ansari, S.S.; Biddle, S.; Borodulin, K.; Buman, M.P.; Cardon, G.; Carty, C.; Chaput, J.P.; Chastin, S.; Chou, R.; et al.
World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br. J. Sports Med. 2020, 54, 1451–1462.
[CrossRef] [PubMed]
6. World Health Organization. Global Action Plan on Physical Activity 2018–2030: More Active People for a Healthier World; World
Health Organization (WHO): Geneva, Switzerland, 2018.
7. Watson, A.; Timperio, A.; Brown, H.; Best, K.; Hesketh, K.D. Effect of classroombased physical activity interventions on academic
and physical activity outcomes: A systematic review and meta-analysis. Int. J. Behav. Nutr. Phys. Act. 2017, 14, 114. [CrossRef]
8. Carson, R.L.; Castelli, D.M.; Beighle, A.; Erwin, H. School-based physical activity promotion: A conceptual framework for
research and practice. Child. Obes. 2014, 10, 100–106. [CrossRef]
9. Amor-Barbosa, M.; Ortega-Martínez, A.; Carrasco-Uribarren, A.; Bagur-Calafat, M.C. Active School-Based Interventions to
Interrupt Prolonged Sitting Improve Daily Physical Activity: A Systematic Review and Meta-Analysis. Int. J. Environ. Res. Public
Health 2022, 19, 15409. [CrossRef] [PubMed]
10. Neil-Sztramko, S.E.; Caldwell, H.; Dobbins, M. School-based physical activity programs for promoting physical activity and
fitness in children and adolescents aged 6 to 18. Cochrane Database Syst. Rev. 2021, 23, CD007651.
11. Yuksel, H.S.; Şahin, F.N.; Maksimovic, N.; Drid, P.; Bianco, A. School-Based Intervention Programs for Preventing Obesity and
Promoting Physical Activity and Fitness: A Systematic Review. Int. J. Environ. Res. Public Health 2020, 17, 347. [CrossRef]
12. Daly-Smith, A.J.; Zwolinsky, S.; McKenna, J.; Tomporowski, P.D.; Defeyter, M.A.; Manley, A. Systematic review of acute physically
active learning and classroom movement breaks on children’s physical activity, cognition, academic performance and classroom
behaviour: Understanding critical design features. BMJ Open Sport Exerc. Med. 2018, 4, e000341. [CrossRef] [PubMed]
13. Infantes-Paniagua, Á.; Silva, A.F.; Ramirez-Campillo, R.; Sarmento, H.; González-Fernández, F.T.; González-Víllora, S.; Clemente,
F.M. Active School Breaks and Students’ Attention: A Systematic Review with Meta-Analysis. Brain Sci. 2021, 11, 675. [CrossRef]
[PubMed]
14. Martin, R.; Murtagh, E.M. Effect of active lessons on physical activity, academic, and health outcomes: A systematic review. Res.
Q. Exerc. Sport 2017, 88, 149–168. [CrossRef] [PubMed]
15. Goh, T.L.; Hannon, J.; Webster, C.A.; Podlog, L.W.; Brusseau, T.; Newton, M. Effects of a classroom-based physical activity
program on children’s physical activity levels. J. Teach. Phys. Educ. 2014, 33, 558–572. [CrossRef]
16. Muñoz-Parreño, J.A.; Belando-Pedreño, N.; Torres-Luque, G.; Valero-Valenzuela, A. Improvements in Physical Activity Levels
after the Implementation of an Active-Break-Model-Based Program in a Primary School. Sustainability 2020, 12, 3592. [CrossRef]
17. Mendoza-Muñoz, M.; Calle-Guisado, V.; Pastor-Cisneros, R.; Barrios-Fernandez, S.; Rojo-Ramos, J.; Vega-Muñoz, A.; Contreras-
Barraza, N.; Carlos-Vivas, J. Effects of Active Breaks on Physical Literacy: A Cross-Sectional Pilot Study in a Region of Spain. Int.
J. Environ. Res. Public Health 2022, 19, 7597. [CrossRef]
18. Mendoza-Muñoz, M.; Carlos-Vivas, J.; Villafaina, S.; Parraca, J.A.; Vega-Muñoz, A.; Contreras-Barraza, N.; Raimundo, A. Effects
of a Physical Literacy Breaks (PLBreaks) Program on Physical Literacy and Body Composition in Portuguese Schoolchildren: A
Study Protocol. Biology 2022, 11, 910. [CrossRef]
19. González-Fernández, F.T.; González-Víllora, S.; Baena-Morales, S.; Pastor-Vicedo, J.C.; Clemente, F.M.; Badicu, G.; Murawska-
Ciałowicz, E. Effect of Physical Exercise Program Based on Active Breaks on Physical Fitness and Vigilance Performance. Biology
2021, 10, 1151. [CrossRef]
20. De Greeff, J.W.; Bosker, R.J.; Oosterlaan, J.; Visscher, C.; Hartman, E. Effects of physical activity on executive functions, attention
and academic performance in preadolescent children: A meta-analysis. J. Sci. Med. Sport 2018, 21, 501–507. [CrossRef]
21. Loturco, I.; Montoya, N.P.; Ferraz, M.B.; Berbat, V.; Pereira, L.A. A Systematic Review of the Effects of Physical Activity on Specific
Academic Skills of School Students. Educ. Sci. 2022, 12, 134. [CrossRef]
22. Jiménez-Parra, J.F.; Belando-Pedreño, N.; López-Fernández, J.; García-Vélez, A.J.; Valero-Valenzuela, A. “ACTIVE VALUES”: An
Interdisciplinary Educational Programme to Promote Healthy Lifestyles and Encourage Education in Values. A Rationale and
Protocol Study. Appl. Sci. 2022, 12, 8073. [CrossRef]
23. Jiménez-Parra, J.F.; Manzano-Sánchez, D.; Camerino, O.; Castañer, M.; Valero-Valenzuela, A. Enhancing Physical Activity in the
Classroom with Active Breaks: A Mixed Methods Study. Apunt. Educ. Fis. Deport. 2022, 147, 84–94. [CrossRef]
Healthcare 2023, 11, 1256 13 of 15

24. Jiménez-Parra, J.F.; Manzano-Sánchez, D.; Camerino, O.; Prat, Q.; Valero-Valenzuela, A. Effects of a Hybrid Program of Active
Breaks and Responsibility on the Behaviour of Primary Students: A Mixed Methods Study. Behav. Sci. 2022, 12, 153. [CrossRef]
[PubMed]
25. Jiménez-Parra, J.F.; Belando-Pedreño, N.; Valero-Valenzuela, A. The Effects of the ACTIVE VALUES Program on Psychosocial
Aspects and Executive Functions. Int. J. Environ. Res. Public Health 2023, 20, 595. [CrossRef]
26. Sevil-Serrano, J.; Aibar, A.; Abós, Á.; Generelo, E.; García-González, L. Improving motivation for physical activity and physical
education through a school-based intervention. J. Exp. Educ. 2022, 90, 383–403. [CrossRef]
27. Podnar, H.; Jurić, P.; Karuc, J.; Saez, M.; Barceló, M.A.; Radman, I.; Starc, G.; Jurak, G.; Ðurić, S.; Potočnik, Ž.L.; et al. Comparative
effectiveness of school-based interventions targeting physical activity, physical fitness or sedentary behaviour on obesity
prevention in 6-to 12-year-old children: A systematic review and meta-analysis. Obes. Rev. 2021, 22, e13160. [CrossRef]
28. Sallis, J.F.; Owen, N.; Fisher, E.B. Ecological models of health behavior. In Health Behavior and Health Education: Theory, Research,
and Practice; Glanz, K., Rimer, B.K., Viswanath, K., Eds.; JosseyBass: San Francisco, CA, USA, 2008; pp. 465–485.
29. Deci, E.L.; Ryan, R.M. The general causality orientations scale: Self-determination in personality. J. Res. Pers. 1985, 19, 109–134.
[CrossRef]
30. Ajzen, I.; Driver, B.L. Prediction of leisure participation from behavioral, normative, and control beliefs: An application of the
theory of planned behavior. Leis. Sci. 1991, 13, 185–204. [CrossRef]
31. Rhodes, R.E.; Janssen, I.; Bredin, S.S.; Warburton, D.E.; Bauman, A. Physical activity: Health impact, prevalence, correlates and
interventions. Psychol. Health 2017, 32, 942–975. [CrossRef]
32. Thyer, B.A. Quasi-Experimental Research Designs; Oxford University Press: Oxford, UK, 2012.
33. Hoffmann, T.C.; Glasziou, P.P.; Boutron, I.; Milne, R.; Perera, R.; Moher, D.; Altman, D.G.; Barbour, V.; Macdonald, H.; Johnston,
M.; et al. Better reporting of interventions: Template for intervention description and replication (TIDieR) checklist and guide.
BMJ 2014, 348, 348. [CrossRef]
34. Vallvé, C.; Artés, M.; Cobo, E. Non-randomised intervention studies (TREND). Med. Clin. 2005, 125, 38–42. [CrossRef]
35. Cordero-Aguilar, M.J.; Sánchez-López, A.M.; Guisado-Barrilao, R.; Rodriguez-Blanque, B.R.; Noack-Segovia, J.; Cano-Pozo, M.D.
Description of the accelerometer as a method for assessing physical activity in different periods of life: A systematic review. Nutr.
Hosp. 2014, 29, 1250–1261. [CrossRef]
36. Delisle-Nyström, C.; Pomeroy, J.; Henriksson, P.; Forsum, E.; Ortega, F.B.; Maddison, R.; Migueles, J.H.; Löf, M. Evaluation of the
wrist-worn ActiGraph wGT3x-BT for estimating activity energy expenditure in preschool children. Eur. J. Clin. Nutr. 2017, 71,
1212–1217. [CrossRef] [PubMed]
37. Karaca, A.; Demirci, N.; Yılmaz, V.; Hazır Aytar, S.; Can, S.; Ünver, E. Validation of the ActiGraph wGT3X-BT Accelerometer for
Step Counts at Five Different Body Locations in Laboratory Settings. Meas. Phys. Educ. Exerc. Sci. 2022, 26, 63–72. [CrossRef]
38. Kim, Y.; Barry, V.W.; Kang, M. Validation of the ActiGraph GT3X and activPAL accelerometers for the assessment of sedentary
behavior. Meas. Phys. Educ. Exerc. Sci. 2015, 19, 125–137. [CrossRef]
39. Santos-Lozano, A.; Marín, P.J.; Torres-Luque, G.; Ruiz, J.R.; Lucía, A.; Garatachea, N. Technical variability of the GT3X accelerom-
eter. Med. Eng. Phys. 2012, 34, 787–790. [CrossRef]
40. Santos-Lozano, A.; Santin-Medeiros, F.; Cardon, G.; Torres-Luque, G.; Bailon, R.; Bergmeir, C.; Ruiz, J.R.; Lucia, A.; Garatachea,
N. Actigraph GT3X: Validation and determination of physical activity intensity cut points. Int. J. Sports Med. 2013, 34, 975–982.
[CrossRef]
41. Cliff, D.P.; Reilly, J.J.; Okely, A.D. Methodological considerations in using accelerometers to assess habitual physical activity in
children aged 0–5 years. J. Sci. Med. Sport 2009, 12, 557–567. [CrossRef]
42. Plasqui, G.; Bonomi, A.G.; Westerterp, K.R. Daily physical activity assessment with accelerometers: New insights and validation
studies. Obes. Rev. 2013, 14, 451–462. [CrossRef]
43. Trost, S.G.; Mciver, K.L.; Pate, R.R. Conducting accelerometer-based activity assessments in field-based research. Med. Sci. Sports
Exerc. 2005, 37, S531–S543. [CrossRef]
44. Matthews, C.E.; Hagströmer, M.; Pober, D.M.; Bowles, H.R. Best practices for using physical activity monitors in population-based
research. Med. Sci. Sports Exerc. 2012, 44, S68. [CrossRef]
45. Evenson, K.R.; Catellier, D.J.; Gill, K.; Ondrak, K.S.; McMurray, R.G. Calibration of two objective measures of physical activity for
children. J. Sport Sci. 2008, 26, 1557–1565. [CrossRef]
46. Fernández-Hernández, A.; Manzano-Sánchez, D.; Jiménez-Parra, J.F.; Valero-Valenzuela, A. Analysis of differences according to
gender in the level of physical activity, motivation, psychological needs and responsibility in Primary Education. J. Hum. Sport
Exerc. 2021, 16, 580–589. [CrossRef]
47. Ortega, F.B.; Artero, E.G.; Ruiz, J.R.; España-Romero, V.; Jiménez-Pavón, D.; Vicente-Rodríguez, G.; Moreno, L.A.; Manios, Y.;
Béghin, L.; Ottevaere, C.; et al. Physical fitness levels among European adolescents: The HELENA study. Br. J. Sports Med. 2010,
45, 20–29. [CrossRef]
48. Ruiz, J.R.; España Romero, V.; Castro Piñero, J.; Artero, E.G.; Ortega, F.B.; Cuenca García, M.; Jiménez Pavón, D.; Chillón, P.;
Girela Rejón, M.J.; Mora, J.; et al. ALPHA-fitness test battery: Health-related field-based fitness tests assessment in children and
adolescents. Nutr. Hosp. 2011, 26, 1210–1214. [CrossRef]
Healthcare 2023, 11, 1256 14 of 15

49. Cole, T.J.; Bellizzi, M.C.; Flegal, K.M.; Dietz, W.H. Establishing a standard definition for child overweight and obesity worldwide:
International survey. BMJ 2000, 320, 1240–1243. [CrossRef]
50. Milanovic, I.; Janic, S.R.; Zivkovic, M.Z.; Mirkov, D.M. Health-related physical fitness levels and prevalence of obesity in Serbian
elementary schoolchildren. Nutr. Hosp. 2019, 36, 253–260. [CrossRef]
51. Council of Europe, Committee for Development of Sport. Eurofit: European Tests of Physical Fitness; Edigraf Editoriale Grafica:
Rome, Italy, 1988.
52. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription, 11th ed.; Wolters Kluwer Health:
Alphen aan den Rijn, The Netherlands, 2021.
53. Tomkinson, G.R.; Carver, K.D.; Atkinson, F.; Daniell, N.D.; Lewis, L.K.; Fitzgerald, J.S.; Lang, J.J.; Ortega, F.B. European normative
values for physical fitness in children and adolescents aged 9–17 years: Results from 2,779,165 Eurofit performances representing
30 countries. Br. J. Sports Med. 2018, 52, 1445–1456. [CrossRef]
54. Ayala, F.; Sainz de Baranda, P.; De Ste Croix, M.; Santonja, F. Reliability and validity of sit-and-reach tests: A systematic review.
Rev. Andal. Med. Deport. 2012, 5, 57–66. [CrossRef]
55. Grgic, J. Test–retest reliability of the EUROFIT test battery: A review. Sport Sci. Health 2022, 1–8. [CrossRef]
56. Léger, L.A.; Lambert, J.A. Maximal multistage 20-m shuttle run test to predict VO2 max. Eur. J. Appl. Physiol. Occup. Physiol. 1982,
49, 1–12. [CrossRef]
57. Lee, O.; Choi, E. The influence of professional development on teachers’ implementation of the Teaching Personal and Social
Responsibility model. J. Teach. Phys. Educ. 2015, 34, 603–625. [CrossRef]
58. Braithwaite, R.; Spray, C.M.; Warburton, V.E. Motivational climate interventions in physical education: A meta-analysis. Psychol.
Sport Exerc. 2011, 12, 628–638. [CrossRef]
59. Hastie, P.; Casey, A. Fidelity in models-based practice research in sport pedagogy: A guide for future investigations. J. Teach. Phys.
Educ. 2014, 33, 422–431. [CrossRef]
60. Camerino, O.; Valero-Valenzuela, A.; Prat, Q.; Manzano-Sánchez, D.; Castañer, M. Optimizing education: A mixed methods
approach oriented to teaching personal and social responsibility (TPSR). Front. Psychol. 2019, 10, 1439. [CrossRef]
61. Wright, P.M.; Craig, M.W. Tool for assessing responsibility-based education (TARE): Instrument development, content validity,
and inter-rater reliability. Meas. Phys. Educ. Exerc. Sci. 2011, 15, 204–219. [CrossRef]
62. Organic Law 8/2013, for the Improvement of Educational Quality. Available online: https://www.boe.es/eli/es/lo/2013/12/09
/8 (accessed on 31 December 2022).
63. Hellison, D. Teaching Responsibility through Physical Activity; Human Kinetics Publishers: Champaign, IL, USA, 2011.
64. Escartí, A.; Llopis-Goig, R.; Wright, P.M. Assessing the Implementation Fidelity of a School-Based Teaching Personal and Social
Responsibility Program in Physical Education and Other Subject Areas. J. Teach. Phys. Educ. 2018, 37, 12–23. [CrossRef]
65. Steinskog, D.J.; Tjøstheim, D.B.; Kvamstø, N.G. A cautionary note on the use of the Kolmogorov–Smirnov test for normality. Mon.
Weather Rev. 2007, 135, 1151–1157. [CrossRef]
66. Cohen, J. Statistical Power Analysis for Behavioral Sciences; Erlbaum Associates: New York, NY, USA, 1988.
67. Norris, E.; Dunsmuir, S.; Duke-Willliams, O.; Stamatakis, E.; Shelton, N. Physically active lessons improve lesson activity and
on-task behavior: A cluster-randomized controlled trial of the “virtual traveller” intervention. Health Educ. Behav. 2018, 45,
945–956. [CrossRef]
68. Donnelly, J.; Greene, J.; Gibson, C.; Smith, B.; Washburn, R.; Sullivan, D.; DuBose, K.; Mayo, M.S.; Schmelzle, K.H.; Ryan, J.J.;
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, 336–341. [CrossRef]
69. Riley, N.; Lubans, D.R.; Holmes, K.; Morgan, P.J. Findings from the EASY minds cluster randomized controlled trial: Evaluation
of a physical activity integration program for mathematics in primary schools. J. Phys. Act. Health 2016, 13, 198–206. [CrossRef]
70. Van den Berg, V.; Saliasi, E.; de Groot, R.H.M.; Chinapaw, M.J.M.; Singh, A.S. Improving cognitive performanceof 9–12 years old
children: Just dance? A randomize control trial. Front. Psychol. 2019, 10, 174. [CrossRef]
71. Watson, A.J.L.; Timperio, A.; Brown, H.; Hesketh, K.D. A pilot primary school active breakprogram (ACTI-BREAK): Effects on
academic and physical activity outcomes forstudents in Years 3 and 4. J. Sci. Med. Sport 2019, 22, 438–443. [CrossRef]
72. Martin, R.; Murtagh, E. Active classrooms: A cluster randomized controlled trial evaluating the effects of a movement integration
intervention on the physical activity levels of primary school children. J. Phys. Act. Health 2017, 14, 290–300. [CrossRef]
73. Ridgers, N.D.; Timperio, A.; Cerin, E.; Salmon, J. Compensation of physical activity and sedentary time in primary school children.
Med. Sci. Sports Exerc. 2014, 46, 1564–1569. [CrossRef]
74. Drummy, C.; Murtagh, E.M.; McKee, D.P.; Breslin, G.; Davison, G.W.; Murphy, M.H. The effect of a classroom activity break on
physical activity levels and adiposity in primary school children. J. Paediatr. Child Health 2016, 52, 745–749. [CrossRef]
75. Li, Y.P.; Hu, X.Q.; Schouten, E.G.; Liu, A.L.; Du, S.M.; Li, L.Z.; Cui, Z.H.; Wang, D.; Kok, F.J.; Hu, F.B.; et al. Report on childhood
obesity in China (8): Effects and sustainability of physical activity intervention on body composition of Chinese youth. Biomed.
Environ. Sci. 2010, 23, 180–187. [CrossRef]
76. Torbeyns, T.; Geus, B.; Bailey, S.; Decroix, L.; Cutsem, J.; Pauw, K.; Meeusen, R. Bike desks in the classroom: Energy expenditure,
physical health, cognitive performance, brain functioning, and academic performance. J. Phys. Act. Health 2017, 14, 429–439.
[CrossRef]
Healthcare 2023, 11, 1256 15 of 15

77. Masini, A.; Marini, S.; Gori, D.; Leoni, E.; Rochira, A.; Dallolio, L. Evaluation of school-based interventions of active breaks in
primary schools: A systematic review and meta-analysis. J. Sports Sci. Med. 2020, 23, 377–384. [CrossRef]
78. Seljebotn, P.H.; Skage, I.; Riskedal, A.; Olsen, M.; Kvalø, S.E.; Dyrstad, S.M. Physically active academic lessons and effect on
physical activity and aerobic fitness. The Active School study: A cluster randomized controlled trial. Prev. Med. Rep. 2019, 13,
183–188. [CrossRef]

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.