A real world feasibility trial of the PLAYshop: an intervention to facilitate parent engagement in developing their child’s physical literacy


 Background

Development of physical literacy, defined as “the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life”, can support children’s physically active behaviors and consequent health benefits. Little research exploring interventions to improve children's physical literacy exist, although substantive evidence shows parents play a key role in children's physically active behaviors and development of fundamental movement skills. The purpose of this study is to explore a novel, physical literacy intervention designed to assist parents to engage with their child in purposeful play; play that facilitates the development of physical literacy.
Methods

The PLAYshop was a 75-minute workshop to build parents' self-efficacy to support their child’s physical literacy through interactive activities and educational messages as well as educational resources focused on core physical literacy concepts. We collected quantitative pre- and post-workshop surveys of parents’ satisfaction, knowledge, confidence and intention to adopt practices as well as qualitative follow-up implementation focused interviews from both parents and facilitators. We used paired t-tests to examine changes in parents' self-reported physical literacy knowledge and confidence and thematic analysis of interviews to explore workshop feasibility.
Results

Six workshops were delivered to 33 parents of young children (3–8 years of age). 23 parents completed both pre- and post-workshop surveys. Follow-up interviews were completed with 11 parents and four workshop facilitators. Parents’ self-reported knowledge and confidence to support their child’s physical literacy development significantly increased after PLAYshop participation. Further, the majority of parents were satisfied with the workshop and motivated to apply workshop learnings at-home with their child. Workshop facilitators identified seven workshop strengths (e.g., workshop champions and skilled facilitators) and four challenges (e.g., recruitment and unfavorable spaces).
Conclusions

The PLAYshop was perceived positively by parents and facilitators and appeared to improve parent self-efficacy and intention to promote physical literacy with their child. Recruitment and attendance were key implementation challenges. The findings from this real world trial address an important evidence gap, highlighting areas for adaptations to improve the intervention and recruitment and suggesting that the PLAYshop is ready for efficacy testing in a more rigorous randomized controlled trial.


Abstract Background
Development of physical literacy, defined as "the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life", can support children's physically active behaviors and consequent health benefits. Little research exploring interventions to improve children's physical literacy exist, although substantive evidence shows parents play a key role in children's physically active behaviors and development of fundamental movement skills. The purpose of this study is to explore a novel, physical literacy intervention designed to assist parents to engage with their child in purposeful play; play that facilitates the development of physical literacy.

Methods
The PLAYshop was a 75-minute workshop to build parents' self-efficacy to support their child's physical literacy through interactive activities and educational messages as well as educational resources focused on core physical literacy concepts. We collected quantitative pre-and postworkshop surveys of parents' satisfaction, knowledge, confidence and intention to adopt practices as well as qualitative follow-up implementation focused interviews from both parents and facilitators. We used paired t-tests to examine changes in parents' self-reported physical literacy knowledge and confidence and thematic analysis of interviews to explore workshop feasibility.

Results
Six workshops were delivered to 33 parents of young children (3-8 years of age). 23 parents completed both pre-and post-workshop surveys. Follow-up interviews were completed with 11 parents and four workshop facilitators. Parents' self-reported knowledge and confidence to support their child's physical literacy development significantly increased after PLAYshop participation.
Further, the majority of parents were satisfied with the workshop and motivated to apply workshop learnings at-home with their child. Workshop facilitators identified seven workshop strengths (e.g., workshop champions and skilled facilitators) and four challenges (e.g., recruitment and unfavorable spaces).

Conclusions
The PLAYshop was perceived positively by parents and facilitators and appeared to improve parent self-efficacy and intention to promote physical literacy with their child. Recruitment and attendance were key implementation challenges. The findings from this real world trial address an important evidence gap, highlighting areas for adaptations to improve the intervention and recruitment and suggesting that the PLAYshop is ready for efficacy testing in a more rigorous randomized controlled trial.

Background
Physical activity is critically important to the development of young children as it improves cognitive and motor skill development, psychosocial health, social connectedness, and cardio metabolic health as well as reduces adiposity (Carson et al., 2017;Tremblay et al., 2012) and risk of chronic disease in adulthood (Craigie, Lake, Kelly, Adamson, & Mathers, 2011). Physical inactivity has emerged as a public health pandemic (Kohl 3rd et al., 2012) and internationally the prevalence of children participating in sufficient levels of physical activity remains low (Aubert et al., 2018). In response, researchers have developed and tested the effectiveness of numerous childhood physical activity interventions (Messing et al., 2019). Amidst some success, their impact has been limited (Longmuir & Tremblay, 2016;Love, Adams, & van Sluijs, 2019) and several research gaps remain.
Physical literacy offers a relatively new and promising approach for childhood physical activity interventions (Cairney, Dudley, Kwan, Bulten, & Kriellaars, 2019). It is defined by the International Physical Literacy Association as "the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life" (IPLA, 2017). Physical literacy is an antecedent to improve and maintain physical activity participation and consequent health benefits (Cairney et al., 2019;Edwards, Bryant, Keegan, Morgan, & Jones, 2017)which makes it particularly important to begin to develop early in the life course. To date, little research has explored the feasibility of interventions designed to improve children's physical literacy, leading to little understanding of "what physical literacy-supportive programs look like in practice" (Jurbala, 2015).
Evidence from systematic reviews indicate that parents play a key role in children's physical activity related behaviors. In a 2016 systematic review of family-based physical activity interventions, 31 of the 47 included studies demonstrated a significant positive effect on children's physical activity levels (Brown et al., 2016). A systematic review of the determinants of physical activity in children aged 0-6 years found that parent monitoring was the only factor consistently associated with children's physical activity (Hesketh et al., 2017). More recently, a synthesis of results from 39 high-quality reviews (Messing et al., 2019) provided strong evidence that parents play a key role in promoting child physical activity across various community settings.
Although previous systematic reviews did not report on physical literacy, many studies included for review examined parent-focused interventions with an emphasis on fundamental movement skills (FMS) -a key domain of physical literacy ( (Barnett et al., 2016;Zeng, Johnson, Boles, & Bellows, 2019). For example, the three month Healthy Dads Healthy Kids (HDHK) program adopted FMS as the exclusive focus for one of the four, 75-minute father/child practical sessions (Morgan, Lubans, Plotnikoff, et al., 2011). Similarly, the eight-week Dads and Daughters Exercising and Empowered (DADEE) program (Morgan et al., 2019) and the mother-daughter MADE4Life program (Barnes, Plotnikoff, Collins, & Morgan, 2015) each devoted at least one practical session to FMS. FMS was an explicit outcome measure within only one intervention trial: a 2018 randomized controlled trial (RCT) of DADEE that found significant improvements in daughters' FMS proficiency (Morgan et al., 2019).
FMS competence was objectively assessed via scores of daughters' performance in six object control skills (kicking, catching, striking a stationary ball, stationary dribble, overhand throw, and underhand throw). Compared to controls, daughters in the intervention had significantly higher object control scores post-intervention (p < .001) that were sustained at 9-month follow up (p ≤ .002).
Positive findings for physical activity-related outcomes were found in trials of all interventions: fathers in DADEE significantly improved in physical activity parenting practices compared to controls (Morgan et al., 2019); children in HDHK significantly increased in level of physical activity compared to controls ; and mothers in MADE4Life reported positive behavior change as a result of the program (Barnes et al., 2015). Further, all of these programs appeared feasible, with high attendance and ratings of program satisfaction made by fathers in HDHK  and DADEE (Morgan et al., 2019), as well as high ratings of program quality and session content made by mothers in MADE4Life (Barnes et al., 2015). These parent-focused interventions inclusive of FMS appear to have a meaningful impact on children's physical activity.
Increasing parent knowledge, confidence and capacity to carry out activities that promote physical literacy may provide children with a foundation for development in this area. No research to-date has explored a parent-focused physical literacy program as an intervention option. This paper aims to address this evidence gap by assessing the feasibility of a novel parent-focused physical literacy intervention aimed at supporting parents to develop their child's physical literacy through play.

The PLAYshop program
The PLAYshop is a theory-based program that builds parents' self-efficacy to assist their child to develop physical literacy and acquire physical activity. The specific objectives of the PLAYshop are: to enhance parents' understanding of physical activity and physical literacy and their role in facilitating it; to expose parents to a number of activities and resources that could help them support the development of a wide range of movement skills and increase physical activity; and to increase parents' confidence in facilitating playful activities by engaging them in the activities (experiential learning) and providing key messages that align with and promote the development of physical literacy (competence, motivation, confidence, and valuing physical activity).
The overall aim of the PLAYshop is to support parents to engage in play with their child that facilitates the development of physical literacy -that is, purposeful play. The program was designed using Bandura's social cognitive theory (Bandura, 1986) with a specific emphasis on parent's self-efficacy and related intervention change techniques described using the Behavior Change Wheel (BCW; a synthesis of 19 behavior change frameworks) (Michie, Van Stralen, & West, 2011). This process identified several behavior change techniques to address factors (capabilities, opportunities and motivation) that might present as barriers and/or enablers to parent's purposeful play with their child.
The resulting implementation strategies are detailed in Table 1. -information about physical literacy a positive outcomes for child -problem solving -messages about addressing multiple developmental goals through physica like numeracy and literacy through si and counting Lack of available resources and/or time to engage in purposeful play with child (physical opportunity)

Trial design
Six physical literacy workshops (the PLAYshop) were delivered at different times and at varying sites (schools, recreation facilities and sport clubs) within two Canadian jurisdictions. This non-randomized study used a one-arm, concurrent nested approach with quantitative data collected through pre-and post-workshop surveys and qualitative data collected through follow-up telephone interviews of parents and PLAYshop facilitators. Human research ethics approval for the study was obtained from the University of Victoria (#16-444) and University of Alberta (#00093764).

Participants
We invited parents of young children (ideally 3-8 years of age) to participate in the PLAYshop using e-flyers distributed through the community networks of the schools, recreation centers, and local sports clubs. Siblings of any age were welcome to join and be involved in the workshop. All parents that showed up on the delivery day were invited to partake in the program, with data obtained only from parents and PLAYshop facilitators who signed a consent form.

Data analysis
Quantitative data: We used SPSS Version 21.0 to analyze all quantitative data. Demographics and descriptive statistics described the population and baseline levels of knowledge, confidence and motivation. Changes in parents' physical literacy knowledge and confidence from baseline to followup were analyzed using paired t-tests. Statistical significance was defined as p<0.05. Measures of frequency (expressed as valid percentages) were calculated to analyze parents' satisfaction with workshop content and delivery and post-workshop intent to participate in physical activities with their children.
Qualitative data: We analyzed qualitative data following principles of framework analysis. Two researchers generated themes for each of parent and facilitator interviews by (1) generating a preliminary coding framework, (2) assigning codes to categories, and (3) developing these into themes and sub-themes via negotiated consensus.

Parent workshop experience
Of the 23 parents who completed post-workshop surveys, the majority reported that they were extremely satisfied with the workshop content (72.7%) and delivery (68.2%), with no parent reporting anything less than somewhat satisfied. Most parents also found the workshop training useful (59.1%).
The workshop content was reported as "somewhat new" by 49% of parents and "very new" by 28.6%.
Most parents (65.2%) were motivated to do physical activity with their children within two weeks of the workshop delivery, and 43.5% strongly disagreed that performing physical activities with their child/children within two weeks of the workshop would be difficult.
Thematic analysis of the follow-up semi-structured interviews of parents (n=11) identified five key themes in relation to implementing the physical literacy activities and concepts (table 1)

Facilitator feedback
Thematic analysis of the semi-structured interviews of workshop facilitators generated two major categories -one relating to strengths and successes (see Table 2) and one relating to challenges and areas for improvement (see Table 3). Each major category was divided into seven themes and four themes respectively, with some themes fitting within both. For instance, the presence of a champion assisted in the success of some workshops while the absence of an champion appeared as a key challenge for others. Similarly, children attending the workshops served as both a challenge (occasional distraction) and strength (assisted with experiential learning and recruitment), and space for movement also served as either a challenge (inadequate space) or strength (ample space).
Facilitator expertise, workshop content and parents' positive response to the workshop all emerged as workshop strengths while the need to support parents after the workshop emerged as an area for improvement. : Umm, so we did allow people to bring their kids. Um was good because then we had enough kinda facilitato to break off into 2 groups. So when we needed to speak parents by themselves we could, and then someone wo games with the kids and then we would come back as a group. F4: ….. so if you had 2 people always delivering-2 facil could be doing physical literacy type games with the ki they're focused on engaging the children while the othe facilitator umm focused on the parents and then it give parents a bit of a break. The parents can focus. You can kinda education piece and then bring it all in together p at the end.

Conducive Spaces
F1: We always had enough gym space. You need enoug You don't need a huge space. …..As long as you have a multipurpose room, you're okay for size F3: We did [the workshop]-the ones that I helped out w did in 2 elementary school gyms and that's like the per amount of space. F4: … just really making sure that [the space] is a settin conducive to movement and to physical literacy type g and play.

Parent Response and Engagement
F1: So, the parents were really enthusiastic. They really the workshops and they really felt supported in what th learned. They asked questions. …. they were very enga F4: The parents seemed to receive [the workshop] well have some parents with their kids there and the kids [a seemed to really be engaged and it was a positive atmo F2: The parents seemed to really like it and took home The ideas I think they liked the best was the fact that th do physical activities at home without much equipment they didn't need to buy a bunch of stuff Workshop Content F1: I think the content. The content works. The content there's little things like if you have a bit longer you can additional messaging… F2: I think the actual content of [the workshop] was goo parents seemed to like that. So I wouldn't change nece that aspect. F4: … and then those key messages… watching some o other workshops that were facilitated primarily by [Faci really the emphasis on those key messages about bein and fun but also [using the play] in order to develop tho and the importance behind that. F4: oh I just think it's so important that we do start-star targeting parents now for the next kind of wave of phys literacy and fundamental movement skills developmen . It is very random. So typically when you're r in all these settings you're going through a third party, parent advisory committee person, inviting the parents their network or the school principal or the sport club te director. So, you have to rely on somebody to send out notices to the list. So that broke down in some cases, b all. F3: I think participation was the biggest one… it's easy to put it out there and say this is gonna happen and I th theory like people want to know this sort of stuff and w able to do and offer and like be able to help their kids s physically active at home and doing all this sort of stuff when it comes time to actually deliver the programs a l those like "maybes, ya sortas" turn into no-shows. F3: … it's easy enough for us to adapt to be able to del something differently to those [smaller] groups and be say like "okay we were going to do this, we'll do this ins because it works better with that group". But at the sam like they maybe don't get the same out of it that a grou parents would because you just-you can't explain the s of things.

Unfavorable Spaces
F1:…outside space is problematic I would suggest that workshop should be done indoors and mostly because w lot of balloons and light things and they blow away. The thing is the ability to bound your space. It's a bit chaosneed an ability to bound your space F4: … ya the classroom was a little broken [up] because the chairs and the tables and I remember thinking that be better had I pushed like the stuff aside and just crea more open inviting atmosphere.

Children as a Distraction
F1: We had some of the kids answering the questions b they sat with the parents at the time, so that was harde then of course you know kids they-there is always one that are precocious, trying to take the lime light in a gr situation. So you need to navigate that a bit.

Discussion
We conducted a small, real world uncontrolled study to assess the feasibility of a brief, parent-focused intervention aimed at enhancing the knowledge, confidence, skills and resources necessary to support them in developing their child's physical literacy through play. According to our results, the majority of parents who partook in the PLAYshop were highly satisfied with both workshop delivery and content. It also appeared to have a positive impact on parents' knowledge, confidence, and engagement in purposeful play with their child/children. Compared to pre-workshop measures, postworkshop surveys of parents showed significantly higher levels of knowledge in key physical literacy variables and confidence in undertaking physical-literacy promoting activities with their child/children.
Further, the majority of parents were highly motivated to apply learnings from the PLAYshop and undertake physical literacy activities with their child/children. Parents and workshop facilitators reported numerous strengths of the PLAYshop content and delivery, including its usefulness, convenience, and ability to elicit enthusiasm from both parents and children.
Further, the workshop brevity, ease to deliver, and low supplies required makes it a realistic public health intervention in an era where resources are often scarce. However, despite these strengths, several implementation barriers were noted (e.g., distracting children, difficulty recruiting parents, and unfavorable delivery spaces). Fortunately, these challenges were exposed in this study and may be mitigated by modifications. For example, an additional facilitator to engage children during parental learning might lessen the distraction -a method successfully employed for the HDHK fatherchild practical sessions .
This study has numerous limitations including the small number of participants and lack of a control group. However, this is common of feasibility studies whose primary purpose is to determine whether future definitive trials of an intervention should take place and if so, what this trial should like (Blatch-Jones, Pek, Kirkpatrick, & Ashton-Key, 2018). Strengths of the study included the workshop delivery with real world partners in the context in which potential scale-up would occur.

Conclusion
The PLAYshop appeared feasible and improved parent self-efficacy to promote physical literacy with their child/children, although recruitment was challenging. Based on these positive results, the planning of a future full-scale RCT is currently underway and outcomes from this study will be used to inform modifications to improve workshop implementation and impact.
This study addresses an important research gap and is a valuable preliminary step in the development, testing and delivery of an intervention to promote childhood physical literacy. It contributes to the broader physical literacy movement that strives for children to have "the motivation, confidence, knowledge, skills, and fitness necessary to enjoy a physically active lifestyle" (Longmuir & Tremblay, 2016

Consent for publication: Not applicable.
Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests:
The authors declare that they have no competing interests.  PLAYshopMinimumStandardsofReportingChecklist.docx