current physical education articles

New Research Examines Physical Education in America

By Morgan Clennin, PhD, MPH, Kaiser Permanente of Colorado, University of South Carolina, and National Physical Activity Plan

School-based physical education (PE) is recommended by the Community Guide as an effective strategy to promote physical activity among youth. Unfortunately, many have speculated that PE exposure has declined precipitously among U.S. students in the past decade. Limited resources and budgets, prioritization of core academic subjects, and several other barriers have been cited as potential drivers of these claims. However, few large-scale studies have explored the merit of these claims – leaving the answers following questions unknown:

Has PE attendance decreased among U.S. students in the past decades?

What policies and practices are in place to support quality PE?

To answer these questions, the President’s Council on Sports, Fitness & Nutrition tasked the National Physical Activity Plan Alliance (NPAPA) to review the available evidence and summarize their findings. The primary objective of this effort was to better understand PE exposure over time to inform national recommendations and strategies for PE.

The NPAPA began by establishing a collaborative partnership with experts in the federal government, industry, and academia. The group analyzed existing national data sources that could be used to examine changes in PE attendance and current implementation of PE policies and practices. These efforts culminated in a final report and two peer-reviewed manuscripts. A summary of the group’s findings are outlined below.

Key Findings:

• 1/2 of U.S. high school students did not attend PE classes—which is consistent over the 24-year period studied (1991-2015).
• The percentage of U.S. high school students reporting PE attendance did not change significantly between 1991 and 2015 for the overall sample or across sex and race/ethnicity subgroup.
• Daily PE attendance did decrease 16% from 1991 to 1995 then attendance rates remained stable through 2015.
• > 65% of schools implemented 2-4 of the 7 essential PE policies
• Implementation of PE policies varied by region, metropolitan status, and school level.
• Data indicates minority students have been disproportionately affected by cuts to school PE programs during the past two decades.

Recommendations Based on Key Findings:

• Prioritize efforts to expand collection of surveillance data examining trends in PE attendance among elementary and middle school students.
• Develop policies to improve PE access for all students in order for PE to contribute to increased physical activity among youth.
• Adopt policies and programs that prioritize PE to maximize the benefits of PE.
• Utilize the findings of these efforts to target professional development and technical assistance for PE practitioners.

The Education sector of the NPAP provides evidence-based strategies and tactics that can guide efforts to support the provision of quality PE to all students. More information, and links to the respective manuscripts, can be found on the NPAPA website: http://physicalactivityplan.org/projects/physicaleducation.html

The Office of Disease Prevention and Health Promotion (ODPHP) cannot attest to the accuracy of a non-federal website.

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• Published: 17 December 2020

Physical education class participation is associated with physical activity among adolescents in 65 countries

• Riaz Uddin 1 , 2 , 3 ,
• Jo Salmon 1 ,
• Sheikh Mohammed Shariful Islam 1 , 3 &
• Asaduzzaman Khan 2 , 3  

Scientific Reports volume  10 , Article number:  22128 ( 2020 ) Cite this article

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In this study we examined the associations of physical education class participation with physical activity among adolescents. We analysed the Global School-based Student Health Survey data from 65 countries (N = 206,417; 11–17 years; 49% girls) collected between 2007 and 2016. We defined sufficient physical activity as achieving physical activities ≥ 60 min/day, and grouped physical education classes as ‘0 day/week’, ‘1–2 days/week’, and ‘ ≥ 3 days/week’ participation. We used multivariable logistic regression to obtain country-level estimates, and meta-analysis to obtain pooled estimates. Compared to those who did not take any physical education classes, those who took classes ≥ 3 days/week had double the odds of being sufficiently active (OR 2.05, 95% CI 1.84–2.28) with no apparent gender/age group differences. The association estimates decreased with higher levels of country’s income with OR 2.37 (1.51–3.73) for low-income and OR 1.85 (1.52–2.37) for high-income countries. Adolescents who participated in physical education classes 1–2 days/week had 26% higher odds of being sufficiently active with relatively higher odds for boys (30%) than girls (15%). Attending physical education classes was positively associated with physical activity among adolescents regardless of sex or age group. Quality physical education should be encouraged to promote physical activity of children and adolescents.

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Introduction.

Physical activity is essential for health and wellbeing of children and adolescents 1 . Physical activity improves musculoskeletal, cardiac, metabolic, psychosocial, and cognitive health, and enhances cardiorespiratory and muscular fitness of children and adolescents 1 , 2 , 3 , 4 . Regular participation also decreases adiposity in those who are overweight 3 . For optimal health benefits, the current international guidelines (i.e., the World Health Organization [WHO]) recommends that those aged 5–17-years accumulate at least 60 min of moderate-to-vigorous physical activity daily 5 . Globally, four out of five (81%) adolescents aged 11–17 years do not meet this recommendation and are insufficiently active 6 . Such inactive behaviours during adolescence have both current and future ramifications on health and wellbeing as behaviours such as physical activity established during adolescence can carry over to adulthood 7 , 8 . Therefore, pragmatic strategies to promote physical activity during adolescence around the globe are of critical importance 9 .

Adolescent physical activity occurs in different settings and domains including at home, in the community, for transportation, and at school. Opportunities for physical activity at school include during recess and lunch breaks, school sport and physical education lessons. Physical education classes may provide resources and opportunities for students to accumulate the daily physical activity level and can contribute to daily energy expenditure 10 , 11 . Recent meta-analyses found that 41% of secondary school 12 and 45% of elementary school 13 physical education lessons comprised moderate-to-vigorous physical activity. In many countries, physical education provides children and adolescents the understanding and motivation for an active lifestyle and also creates an environment to acquire knowledge and skills for physical activity throughout life 14 , 15 . In addition, adolescents who may have limited access to space and equipment outside of school can benefit from attending physical education classes at school 10 , 11 . School-based physical education, therefore, can be an accessible source of physical activity for many adolescents and can help develop an active healthy lifestyle 16 . In addition to the number of physical education classes, access to high-quality physical education experience (e.g., teacher behaviours, learning outcomes), which forms the foundation for lifelong engagement in physical activity, is also important for children and adolescents 17 , 18 , 19 .

Available evidence suggest that participation in physical education classes are positively associated with higher levels of physical activity 20 , 21 , 22 , 23 , 24 . However, the evidence is mostly based on single-country studies from high-income countries with limited multi-country study and lack of representation of low- and lower-middle-income countries 25 . A recent multi-country study reported country- and regional-level differences in physical education class participation, which was also differed by sex, age, and country-income classification 26 . In addition, delivery, content and quality of physical education also vary within and between countries 27 , 28 . It is often provided infrequently in schools across countries, and therefore the potential impact on total moderate-to-vigorous physical activity among boys and girls may be limited 29 . In order to obtain a comprehensive global perspective on the relationship between physical education and physical activity, large multi-country studies with representative samples are essential. Given the context and the opportunities that exist in schools for physical activity promotion, in this study, we aimed to examine whether participation in physical education classes (i.e., number of physical education class attendance) is associated with sufficient level of physical activity among adolescents (overall, and by sex and age-group) from 65 countries around the globe. We hypothesised that higher number of physical education class participation would be positively associated with sufficient level of physical activity among adolescents.

Data source

Data for this study were from the Global School-based Student Health Survey (GSHS), a population-based survey of school-going children and adolescents around the world 30 . In all participating countries, the GSHS uses the same standardised sampling technique and study methodology. All participants completed a standardised self-administered anonymous questionnaire, which included, but was not limited to, questions on demographics (e.g., age, sex), participation in physical education classes and physical activity. GSHS adopted questionnaire items, including items to measure physical activity and physical education from the Youth Risk Behavior Survey of American Adolescents. Countries, where GSHS were implemented, were encouraged to use culturally appropriate examples, words, and phrases to ensure sociocultural adaptability of the items. Furthermore, using a rigorous translation and back-translation process with the assistance of WHO and US CDC, countries were allowed to translate the questionnaire into their local language 31 .

As of 8 December 2019, 98 countries/territories around the globe had at least one GSHS dataset publicly available with the surveys being conducted between 2007 and 2016. For countries with more than one GSHS dataset, we used the most recent one available. Of the 98 countries, 84 countries had data on PA, while 67 countries had data on physical education. Two countries (Niue and Tokelau) were excluded from the analyses due to their small sample size (n < 140). The analytical sample consists of 206,417 adolescents aged 11 or younger to 17 years from 65 countries. Only a small proportion of students (1.05%) were in the age group “11 years old or younger”, and for modelling purposes, they were considered as 11 years old for this analysis, as it was not possible to determine what proportion of 1.05% students were younger than 11 years old. All countries provided nationally representative samples.

The GSHS received ethics approval from the Ministry of Education or a relevant Institutional Ethics Review Committee, or both in each of the participating countries. Only those adolescents and their parents who provided written or verbal consent participated. As the current study used retrospective, de-identified, publicly available data, ethics approval was not required for this secondary analysis. Detailed methods of the GSHS have been described on both the US CDC and the WHO websites 30 , 32 .

Outcome measure—physical activity participation

Physical activity was assessed with one item: ‘During the past 7 days, on how many days were you physically active for a total of at least 60 min per day?’ The response options were 0–7 days. Consistent with the WHO recommendations 5 , we defined participants as ‘sufficiently active’ who did ≥ 60 min/day of physical activity on seven days of the week.

Study factor—physical education participation

Physical education class attendance was assessed with one item: ‘During this school year, on how many days did you go to physical education (PE) class each week?’ The responses were classified into three groups: ‘0 day/week’, ‘1–2 days/week’, and ‘≥ 3 days/week’ as used elsewhere 25 , 33 .

Adolescents self-reported age, sex, and daily hours of sitting (when not in school or doing homework) in the survey. Food insecurity was assessed by asking: ‘During the past 30 days, how often did you go hungry because there was not enough food in your home?’ with response options being never, rarely, sometimes, most of the time, and always. As the GSHS did not include any direct measure of socioeconomic status, this variable was used as a proxy measure of socioeconomic status 34 , 35 . Self-reported height and weight were used to compute body mass index (BMI), which was categorised as underweight (BMI < −2SD), overweight (BMI >  + 1SD), and obese (BMI >  + 2SD), relative to median BMI, by age and sex based on the WHO Child Growth Standards 36 .

Statistical analyses

Of the 65 countries with data on physical activity and physical education, nine countries were from Africa, 20 from the Americas, 15 from Eastern Mediterranean, five from South East Asia, and 16 from the Western Pacific region. Using the World Bank country classification, collected at the time of the survey for the respective countries, seven countries were classified as low‐income, 21 lower‐middle‐income, 18 upper‐middle‐income, and 18 high-income. Income classification information was not available for Cook Island. The prevalence estimates of physical activity and physical education were obtained by using a Stata command ‘svyset’ to take into account sampling weights and the clustered sampling design of the surveys.

In examining the country-level association of physical education with physical activity, a set of covariates was considered including age, sex, weight status (i.e., BMI), food insecurity, and sitting time. Sitting time was considered as an adjusting factor given its demonstrated association with physical activity in adolescents 37 . Given the binary nature of physical activity outcome, logistic regression analysis with robust standard errors was used to examine the association at the country level, by taking into account the sampling weight that was applied to each participant record to adjust for non-response and the varying probability of selection. This GSHS weighting factor was applied in an identical way to estimate the association in each participating country. Within the GSHS protocol, weighting accounted for the probability of selection of schools and classrooms, non-responding schools and students, and distribution of the population by sex and grade.

Random effects meta-analysis was used to generate pooled estimates of the association between physical education and physical activity for the overall sample, by country income category (e.g., low-income, lower-middle income, upper-middle income, and high-income), and by WHO region, stratified by sex and age groups (11–14 years vs 15–17 years). Two age groups (11–14 years [early adolescence] and 15–17 years [middle adolescence]) 38 were considered to stratify the analysis in order to examine whether the association estimates vary across phases of adolescence. This analysis used DerSimonian and Laird method 39 with the estimate of heterogeneity being taken from the Mantel–Haenszel model. As the GSHS were conducted across different cultural settings in 65 countries around the world over a long period of time (2007–2016), it was reasonable to assume that the association estimates across countries were likely to vary from survey to survey, which supports the use of random effects meta-analysis that can adjust heterogeneity among studies 40 . The percentage of variability in estimates across studies that is attributable to between study heterogeneity (I 2 ) in our analysis ranges from 54.3 to 80.2%, which suggests a strong presence of heterogeneity in the association estimates, and further supports the use of random effects meta-analysis. All adjusted estimates of the association parameters are presented in the form of odds ratio (OR) and 95% confidence interval (CI). All analyses were conducted by StataSE V14.0.

Ethics approval and consent to participate

The GSHS received ethics approval from both a national government administration and an institutional review board or ethics committee. Only adolescents and their parents who provided written/verbal consent participated. As the current study used retrospective publicly available data, we did not require ethics approval from any Institutional Ethics Review Committee for this secondary analysis.

The mean age of the participating adolescents (n = 206,417) was 14.35 (SD = 1.45) years, 54.4% aged 11–14 years, and 49.2% were girls. The prevalence of sufficient physical activity was 15.0%, with boys having higher prevalence (18.3%) than girls (11.5%). Over half (56.5%) of adolescents participated in physical education classes 1–2 days/week (boys 54.7%; girls 58.3%) and about a quarter (24.2%) participated in physical education classes ≥ 3 days/week (boys 26.8%; girls 21.6%). As shown in Fig.  1 , the overall percentage of adolescents being sufficiently active was greater for those who attended more physical education classes in both sexes.

Proportion of adolescents sufficiently physically active by participation in physical education classes, Global School-based Student Health Survey, 2007–2016.

Estimates of associations of physical education class participation with sufficient physical activity by country are shown in Table 1 . The country-level analysis shows that 50 out of 65 participating countries (77%) demonstrated significant and positive associations between attending physical education classes ≥ 3 days/week and being sufficiently active with 33 countries (51%) revealing at least double the odds (OR ≥ 2.0) of meeting physical activity guidelines. For example, Bolivian adolescents who attended physical education classes ≥ 3 days/week had threefold odds of reporting sufficient physical activity compared with their counterparts who attended no physical education class (OR 3.00, 95% CI 1.93–4.67). In examining the association between attending physical education classes 1–2 days/week and being sufficiently active, 20 countries (31%) demonstrated significant positive associations. For example, Thai adolescents who attended physical education classes 1–2 days/week had double the odds to reporting sufficient physical activity compared with their counterparts who attended no physical education class (OR 2.11, 95% CI 1.39–3.19). As shown in Table 1 , attending physical education classes ≥ 3 days/week was positively and strongly associated with physical activity in all WHO regions with South East Asia region showing the strongest association (OR 2.89, 2.11–3.97), followed by Africa (OR 2.45, 1.72–3.48) and Western Pacific region (OR 2.40, 1.92–3.00). The analysis also showed evidence of positive and moderate association between attending physical education classes 1–2 days/week and being sufficiently active in all WHO regions with the pooled association estimates ranging from OR 1.19 (1.01–1.41) in the Americas region to OR 1.86 (1.03–3.36) in South East Asia.

Overall, adolescents who took physical education classes ≥ 3 days/week, compared to those who did not take any physical education classes, had double the odds of being sufficiently active (OR 2.05, 95% CI 1.84–2.28) with no apparent gender (OR 2.09, 1.88–2.33 for boys; and OR 1.95, 1.69–2.25 for girls) or age (OR 2.19, 1.93–2.48 for 11–14-year-old; and OR 2.03, 1.80–2.28 for 15–17-year-old adolescents) differences (Table 2 ). Adolescents who participated in physical education classes 1–2 days/week had 26% higher odds of being sufficiently active (OR 1.26, 1.15–1.37) with relatively higher odds for boys (OR 1.30, 1.17–1.46) than girls (OR 1.15, 1.03–1.29) and younger adolescents aged 11–14 years (OR 1.28, 1.16–1.42) that older adolescents aged 15–17 years (OR 1.19, 1.08–1.32).

The odds of attending physical education classes ≥ 3 days/week and being sufficiently active were lower in country with higher income (Table 2 ). In low-income countries, adolescents who participated in physical education classes ≥ 3 days/week had 137% higher odds of being sufficiently active (OR 2.37, 1.51–3.73) with comparable odds for boys (OR 2.51, 1.70–3.70) and girls (OR 2.36, 1.31–4.26) and slightly higher odds for younger (OR 2.94, 1.92–4.51) than older adolescents (OR 2.32, 1.36–3.96). In high-income countries, the odds of being sufficiently active was 85% higher for adolescents who attended physical education classes ≥ 3 days/week (OR 1.85; 1.52–2.25) with no apparent gender (boys OR 1.89, 1.50–2.37; girls OR 1.69, 1.36–2.10) or age (younger OR 1.83, 1.47–2.28; older OR 1.80 (1.48–2.19) differences. In lower-middle income countries, adolescents who attended physical education classes 1–2 days/week had 39% higher odds of being sufficiently active (OR 1.39, 1.19–1.62) compared to their counterparts who did not take any physical education classes, with relatively higher odds for boys (OR 1.46, 1.21–1.76) than girls (OR 1.30, 1.03–1.65), and similar odds for younger (OR 1.36, 1.09–1.68) and older adolescents (OR 1.33, 1.16–1.51).

Boys of South East Asian region who participated in physical education classes ≥ 3 days/week had the highest odds of being sufficiently active (OR 3.29, 1.97–5.47), followed by the boys of Africa region (OR 2.41, 1.74–3.33) (Supplementary Table S1 ). Girls of Western Pacific and Africa region who participated in physical education classes ≥ 3 days/week had the highest odds of being sufficiently active (OR 2.68, 1.89–3.77, and OR 2.63, 1.63–4.26, respectively). Even by attending physical education classes 1–2 days/week, boys of the Americas region and girls of Africa region can increase their odds, though not considerably, of being sufficiently active (OR 1.29, 1.06–1.58, and OR 1.41, 1.15–1.73, respectively).

Both younger and older adolescents in all WHO regions demonstrated positive association between ≥ 3 days/week physical education class attendance and meeting the physical activity recommendations (Supplementary Table S1 ). Younger adolescents in South East Asia (OR 3.03, 2.42–3.79) and Africa (OR 2.95, 2.07–4.20), and older adolescents in South East Asia (OR 3.24, 1.57–6.67) who participated in physical education classes ≥ 3 days/week had over three times higher odds of being sufficiently active. There were moderate positive associations between physical education class attendance for 1–2 days/week and meeting the physical activity recommendations for younger adolescents in Africa (OR 1.38, 1.03–1.84), the Americas (OR 1.29, 1.07–1.56), and Eastern Mediterranean regions (OR 1.24, 1.06–1.44), and for older adolescents in Africa (OR 1.24, 1.03–1.48), Eastern Mediterranean (OR 1.26, 1.07–1.49), and Western Pacific region (OR 1.19, 1.01–1.41).

To our knowledge, this is the most extensive global study to assess the association of physical education class attendance with physical activity of adolescents, based on nationally representative samples from 65 countries around the globe. The key finding of our study is that adolescents, irrespective of sex or age, who had a higher frequency (≥ 3 days/week) of physical education class attendance had significantly higher odds of meeting the WHO’s physical activity recommendations. The estimates of association between the frequency of attending physical education and meeting physical activity recommendations were lower among countries with higher income. We observed some regional differences with South East Asia having the highest associations and the Americas having the lowest. Our findings suggest that adolescents, especially girls and those aged 15–17 years, are mostly benefited from a higher frequency (i.e., ≥ 3 days/week) of physical education participation. Our study also found some benefits of less frequent participation in physical education classes (1–2 days/week) in meeting the physical activity guidelines, which is encouraging. About one-third of the countries demonstrated positive association between less frequent participation in physical education classes and meeting the physical activity recommendations, and such association was prominent in boys and younger adolescents in all but low-income countries. Our study thus argues that even less frequent participation in physical education classes can bring some benefits for some adolescents.

Our finding that a higher frequency of physical education class attendance was positively associated with meeting the physical activity recommendations is consistent with other studies in children and adolescents 20 , 21 , 24 , 25 . It has been argued that participation in physical education classes acts as a positive reinforcement to “keep young people going” by being more physically active with less time in sedentary behaviour throughout the day 25 . Physical education classes provide children with an opportunity to familiarise themselves with different types of physical activity, motivates them to be active within the school environment, and potentially also encourages more out-of-school physical activity 41 . Physical activity during physical education classes may reduce fatigue and improve mood by changing neurophysiological stimulation and the brain’s information processing function (i.e., cerebral cortex), which may improve children’s preparedness to move more throughout the day 25 . While the frequency of physical education class is important, it is also critical that children have access to quality physical education 18 , 19 . Previously, researchers have suggested that in spite of the traditional class-based and sports-centred physical education curriculum, physical education ought to be a health-centred dynamic learning experience for children 19 , 42 . Quality physical education is important for age-appropriate cognitive learning and to acquire fitness, develop motor skills and psychosocial and emotional skills, which can help children to lead an active lifestyle, inside and outside of the school environment, throughout their life course 18 , 19 , 42 . Given the role of physical education for active and healthy lifestyle, different stakeholders, including United Nations agencies (i.e., UNESCO) 19 , European Commission 17 , have recommended to ensure quality physical education for children and adolescents, and called for political commitments and actions from Governments and supports from the international communities.

In our study, adolescents boys and girls in low-income countries with ≥ 3 days/week physical education class attendance had the highest odds of meeting the physical activity recommendations, and the associations became smaller (yet significant) with a higher country income classification for both sexes. A previous 12-country study 25 reported similar findings for boys, but not for girls. Unlike our study that is based on self-reported data, the earlier study used a device-based physical activity measure and included Australia and other high-income countries of Europe and North America. In addition to high-income countries, our study included adolescents from low- and lower-middle-income countries. It is possible that for many children, regardless of sex or country income, schools provide the most pragmatic and readily accessible opportunities for various physical activity, while out-of-school physical activity options, logistics, and environments might be variable 10 , 11 . The environments, in general, may be more supportive of out of school physical activity for children in high-income countries than their counterparts in low-income countries; however, high-income countries may have other challenges including gender and socioeconomic disparities in physical activity. For example, children from high-poverty neighbourhood may have fewer opportunities for out of school physical activity in many high-income countries 43 , 44 . Appreciating the heterogeneity in resources for physical education within- and across countries, all governments should consider schools as the primary focus to promote an active and healthy lifestyle among children and adolescents, which is likely to be a cost-effective and opportunistic initiative to get them moving. Our findings also show that physical education is potentially more important in South East Asia than the Americas in promoting physical activity. In addition to environmental support, such variations could be a sign of the quality of the respective physical education programs, including time allocated for physical education across the countries. There is a large heterogeneity in weekly time allocated for physical education in countries around the globe. For example, weekly time for physical education of secondary school students in Bangladesh (180 min) is reportedly higher than in Peru (90 min) 28 . Research is needed to understand whether physical education classes are designed to facilitate physical activity and/or how much time students actually spend in physical activity during physical education classes. It is also important to understand how physical education lessons can help the students to develop skills so that they can be more active both inside and outside of school. This information can help in designing a physical education curriculum with balanced components of physical activity and physical education lessons on other health and wellbeing so that the students can develop a healthy lifestyle. Opportunities for quality physical education should be equitable and inclusive, and available for all children regardless their gender, disability status, socio-economic position, and cultural or religious backgrounds, and the delivery of physical education should be ensured for marginalised and vulnerable groups 19 .

The strengths of our study are the inclusion of a large number of countries around the globe, representing different world regions and income groups. All countries included in our study provided nationally representative data. We used the GSHS sample weighting to account for distribution of the population by age and sex in countries for whose data were analysed. Any potential skewness, by sex or age, in the observed data is unlikely to impact the weighted analysis results. All countries where GSHS was implemented, used a standardised data collection procedure. In all countries, a standardised questionnaire with the same survey items to assess physical activity and physical education class attendance was used, which facilitated our regional comparisons. We adjusted our estimates for several potential covariates to avoid possible confounding effects of these factors.

The findings of our study should be interpreted in light of its limitations. Data for our study were collected using self-reported questionnaire; these data are vulnerable to social desirability and recall bias. Unavailability of GSHS data from European and North American countries, some of the Latin/Central American and Asia and Pacific countries, limits the generalisability of the findings only to the GSHS participating countries. Although a standardised questionnaire was used in all participating countries, there is a lack of information on the reliability and validity of GSHS measures across different countries or cultures. Physical education classes can have different meanings and can constitute different components, including a knowledge-based curriculum component (i.e., lessons and discussions) and/or skill-based physical activity session, in different settings. We did not have any information on components of physical education classes across the participating countries. The cross‐sectional design of the study limits our ability to make any causal inferences from the association estimates. Some adolescents in our study may have had difficulties with understanding the questionnaire because of poor reading skills. In this study, we used data collected between 2007 and 2016, which may have biased the results because of the period effect.

Conclusions

Our study suggests a positive association between regular participation in physical education classes and meeting the physical activity guidelines among children and adolescents around the globe regardless of sex or age group. The odds were lower in high- than low-income countries. The benefits of regular participation in physical education classes to enhance physical activity are universal across all WHO regions, with the highest being observed among adolescents from South East Asian countries. Even less frequent participation in physical education classes (i.e., 1–2 days a week) was related to higher odds of being sufficiently active in all but low-income countries, especially in boys. Thus, the findings support the importance of physical education for ensuring sufficient physical activity among school-going children and adolescents around the globe. Countries must not miss the opportunity to ensure schools deliver a daily or at least 3 days per week of well-designed physical education classes, which can play a vital role in creating active nations around the world.

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Acknowledgements

The authors would like to thank the US Centers for Disease Control and Prevention and the World Health Organization for making the Global School-based Student Health Survey (GSHS) data publicly available for analysis. The authors thank the GSHS country coordinators and other staff members. R.U. is supported by Alfred Deakin Postdoctoral Research Fellowship. J.S. is supported by a National Health and Medical Research Council Leadership Level 2 Fellowship (APP 1176885). S.M.S.I. is supported by the Institute for Physical Activity and Nutrition, Deakin University and a post doctorate fellowship from the National Heart Foundation of Australia (Award #102112).

This research received no external funding.

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R.U.: concept and design study, data analysis and interpretation, drafting manuscript, critical revision of manuscript, final approval; J.S.: data interpretation, critical revision of manuscript, final approval; S.M.S.I.: data interpretation, critical revision of manuscript, final approval; A.K.: concept and design study, data analysis and interpretation, statistical analysis, drafting manuscript, critical revision of manuscript, final approval.

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Uddin, R., Salmon, J., Islam, S.M.S. et al. Physical education class participation is associated with physical activity among adolescents in 65 countries. Sci Rep 10 , 22128 (2020). https://doi.org/10.1038/s41598-020-79100-9

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Journal of Teaching in Physical Education

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Volume 43 (2024): Issue 3 (Jul 2024)

JTPE is published quarterly in January, April, July, and October.

The purpose of the Journal of Teaching in Physical Education is to communicate national and international research and stimulate discussion, study, and critique of teaching, teacher education, and curriculum as these fields relate to physical activity in schools, communities, higher education, and sport. The journal publishes original reports of empirical studies in physical education together with integrative reviews and analyses of educational and methodological issues in the field. Research using a variety of methodological approaches is acceptable for publication. Well-designed replication of previous research is also strongly encouraged. Brief research notes also will be reviewed for possible publication. The coeditors and editorial board encourage the submission of manuscripts that extend knowledge within the focus of the journal.

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JTPE Editors and Reviewers Resource Center

Eligibility criteria and responsibilities of jtpe co-editors.

JTPE  co-editors are selected from the members of the editorial board. Upon selection, they serve as junior co-editor for a specified term of two years. Upon completion of this period, they serve as senior co-editor for another two-year term.

Eligibility Criteria Eligibility for  JTPE  co-editor appointments is based on the following criteria:

1. Co-editor candidates have published three manuscripts in the last five years in tier one journals (requirements: one publication in  JTPE  and one first authorship publication). 2. Co-editor candidates have demonstrated high-quality reviews in a timely manner while on the  JTPE  editorial board (a minimum of six reviews per year during the three-year term). 3. Co-editor candidates have served as  JTPE  editorial board members for six years (i.e., two terms) before selection.

  Responsibilities The  JTPE  co-editor responsibilities include, but are not limited to, the following:

1. Co-editors ensure the validity of the double-anonymous review process. 2. Co-editors maintain confidentiality and objectivity regarding manuscripts and the review process. 3. The senior co-editor submits manuscripts to at least two reviewers expert in the specific area who can be objective and do not have conflicts of interest. In the case that the manuscript content or focus is inappropriate for  JTPE , the coeditors contact the author(s) rather than sending it out for review. 4. Co-editors correspond with authors and reviewers. 5. Co-editors make decisions regarding acceptance/rejection and resubmission/rejection of manuscripts based on reviewers’ feedback/recommendations.

To review more information on the duties of editors, including ethical responsibilities,  click here .

Nomination Process

Nominations for the co-editor positions originate from existing editorial board members and are submitted in writing to the senior co-editor who is responsible for contacting the nominees for their curriculum vitae and letter of interest, as well as for making arrangements for the selection process.

Co-editors are selected by current co-editors from the pool of  JTPE  editorial board members who meet the eligibility criteria and are interested in the position. The co-editors’ selection is ratified by the majority vote of the  JTPE  editorial board.

Co-Editor Publication Process

In the case a co-editor submits a manuscript for publication to  JTPE , the other co-editor assigns a guest co-editor to select reviewers and monitor the review process.

Editorial Board Members

Eligibility criteria and responsibilities for jtpe editorial board membership.

Editorial board members are appointed by the senior co-editor upon consensus of the editorial council (senior and junior co-editors).

Eligibility Criteria Eligibility for new board member appointments is based on the following criteria:

1. Potential editorial board member has obtained a doctoral degree specializing in sport pedagogy or related fields at least five years before serving on the  JTPE  editorial board. 2. Potential editorial board member has published three manuscripts in the last five years in tier one journals (initial membership requirements: one publication in  JTPE  and one first authorship publication). 3. Potential editorial board member has served as a guest reviewer for  JTPE  for one year and completed an adequate number of high-quality, non-biased reviews. 4. Potential editorial board member has demonstrated expertise in areas needed on the board. 5. Potential editorial board member is committed to attending the annual  JTPE  editorial board meetings when possible and to contributing to the mission of  JTPE .  

Responsibilities The members of the  JTPE  editorial board are appointed for three years and are directly accountable to the editors of  JTPE . In turn, the senior editor of  JTPE  is responsible to Human Kinetics, Inc. The  JTPE  editorial board members’ responsibilities include, but are not limited to, the following:

1. JTPE  editorial board members complete a minimum of six reviews per year in a timely manner. 2. JTPE  editorial board members provide respectful and constructive reviews for authors that avoid hurtful language and contribute to providing high-quality papers. 3. JTPE  editorial board members demonstrate confidentiality and objectivity regarding the manuscripts and the review process. 4. JTPE  editorial board members participate in the evaluation of the quality and effectiveness of JTPE to help maintain high standards.

Editorial board membership nominations are requested from existing  JTPE  editorial board members. Board members whose term has been completed and who wish to continue on the board can also nominate themselves as a self-nomination (through a letter of intent only). Nominations should be submitted in writing (preferably via electronic mail) to the senior editor, who is responsible for arranging the review/selection process. Nominees are then asked to submit a curriculum vita to the senior editor, along with a statement expressing their interest in the position and explaining their suitability.

The co-editors of  JTPE  will consider nominees who meet the eligibility criteria and have provided requested materials as potential  JTPE  editorial board members. The  JTPE  editorial board can consist of up to 32 members at a time.

Renewal of JTPE Editorial Board Membership

The co-editors determine the renewal of  JTPE  editorial board membership. Board members, upon completion of their term of service, are invited to continue to serve on the board if they have successfully fulfilled all their responsibilities during their three-year term. This will be determined by the eligibility criteria and their ability to fulfill appropriate responsibilities for  JTPE  editorial board membership.

Reviewer Guidelines

A. guidelines for the review of research-based manuscripts.

I. Appropriateness of Manuscript for  JTPE : The reviewer should comment on the appropriateness of the manuscript (refer to editorial policy of  JTPE ) based on the guidelines below (when they apply). Co-editors make final decisions about the appropriateness of manuscripts.

II. Relevance/Significance of the Study:

1. Is there a theoretical framework and/or is the study and the related construct(s) situated in the existing literature? 2. Is the theoretical framework logically explained or are the constructs tied together to explain how the research project was conceived? 3. Is the rationale for the study clear? 4. Does the literature review provide the most relevant and current scholarship on the topic that enriches an understanding of the theoretical framework or related constructs? 5. Are the purpose and the research questions derived from the literature review and are they consistent with the theoretical framework and/or the related constructs and rationale presented in the introduction? 6. Have the data been published elsewhere? 7. Are the interpretations based on valid, reliable, or trustworthy data/materials? 8. Has the work been sufficiently thorough to warrant publication? 9. What significant, unique, or valuable knowledge will readers learn from the study? 10. Overall, does the study add new knowledge and/or make a significant and/or a unique contribution to the existing literature base?

III. Methodology and Presentation of Results:

General Guidelines

1. Are the research questions specific enough so that the theoretical framework/construct logically leads to the selection of appropriate variables/phenomena for the investigation? 2. Is the research design explicitly explained? 3. Are participants clearly described? 4. Is information offered with regard to having obtained institutional approval and participants’ consent? 5. Are key characteristics of the participants provided? 6. Is the sequence of research procedure logical? 7. Are there sufficient data sources to address the research question(s)?

Guidelines for Quantitative Methods

1. Are variables operationally defined for data collection? 2. Is information about the validity and reliability of the measures reported? 3. Do the validity and reliability of the measures meet acceptable criteria? 4. Are control procedures described in experimental/quasi-experimental designs? 5. Are effective procedures used to minimize the threats to the validity and reliability of the measures? 6. Are statistical analyses compatible with or appropriate to the research questions? 7. Are advantages and disadvantages of using the analyses explained? 8. Were adequate assumptions for the statistical analyses examined and results reported? 9. Were descriptive statistics for the variables (dependent variables in particular) reported? 10. Are the parameters/indexes chosen to report results appropriate (especially in multivariate analyses)? 11. Were results for tests of statistical significance accompanied by effect size indices? 12. Are there any indications of calculation errors? 13. When using single-subject designs, were data paths interpreted appropriately according to accepted visual analysis tactics?

Guidelines for Qualitative Methods

1. Is the type of inquiry and its associated paradigm/perspective specified? 2. Does the author reveal sufficient personal/professional subjectivity for readers to assess the degree of the researcher’s role in the study and influence on the data presented? 3. Is the description of context detailed so that readers can situate the study within its social and educational environment? 4. Are detailed descriptions of key informants provided? 5. Are data collection protocols described? 6. Are sufficient data sources used for an effective triangulation to make the case that the data are trustworthy and credible? 7. If limited data sources were used, were additional efforts made to gather sufficient in-depth information from the sources to address the research questions adequately? 8. Are approaches to establishing trustworthiness appropriate? 9. Are data analysis protocols carefully described to show that the themes/grounded theories have been derived in a logical way?

IV. Discussion and Interpretation:

1. Has the discussion/interpretation of results been linked to the theoretical framework and/or constructs and rationale presented in the introduction? 2. To what extent do the findings make unique contributions to the body of knowledge? 3. Are interpretations of the results based on the data and related to the literature? 4. Are there any indications of over- or under-generalization of the results? 5. To what extent have the results answered the research questions (completely, partially, or not at all)? 6. If there are any critical limitations of the study in any section (e.g., theoretical foundation, methodology, results, and/or discussion), how well has the author addressed them? 7. Are practical implications of the findings presented when appropriate? 8. Are similarities and differences with previous findings noted and discussed? 9. Are unexpected results acknowledged and discussed?

V. Clarity of Information Presentation and Writing:

1. Does the writing allow a clear, accurate, and concise presentation of information? Are the sections coherently connected? 2. Does the writing avoid redundancy? 3. Are concepts clearly defined and explained when they first appear in the manuscript? 4. Has technical jargon been avoided or kept to a minimum? 5. Is the general arrangement of the sections logical? 6. Is it a finished piece of work? 7. Are there inappropriate or missing sections/headers? 8. Does the manuscript conform to the Publication Manual of the American Psychological Association (6th ed., 2010)? 9. Does the abstract present all key components in the manuscript in a very concise manner? 10. Are tables and figures accurate, clear, and concise? 11. Do tables and figures present necessary information that contributes to the understanding of the text, rather than redundant information which duplicates what is already in the text? 12. Is the reference list accurate and do citations in the manuscript accurately match those in the references section? 13. Is the tone of reporting academically appropriate? 14. Is an overly emotional tone avoided? 15. Is the length of the manuscript reasonable? 16. If longer than 28 pages (8.5 x 11, size 12 font), can any part be condensed or omitted without jeopardizing the significance of the manuscript?

B. Guidelines for the Review of Manuscripts Pertaining to Theoretical, Philosophical, and/or Applied Issues of Professional Practice

I. Contribution to the Body of Knowledge/Professional Practice: 

1. Does the author address a significant issue that is relevant to the scope of the journal (teaching/learning in physical education)? 2. Is the most current relevant literature included in the review? 3. Are the arguments based on solid theoretical frameworks, philosophical foundations, and/or empirical evidence? 4. To what extent does the manuscript advance our understanding of the issue? 5. Has the work been sufficiently thorough to warrant publication? 6. Is the quality of the content sufficient to warrant publication?

II. Quality of Information Presentation:

1. Are themes and/or philosophical positions stated clearly? 2. Are appropriate transitions used between/among themes to build logical and compelling arguments? 3. Does the presentation help readers conceptualize issues and arguments effectively? 4. Is the manuscript logically organized to achieve a clearly stated purpose that is suited to this journal? 5. Is the information conceptually integrated and coherently presented?

III. Discussion or Interpretation of Ideas and Information:

1. Has the author built constructive arguments that advance theory, knowledge, and/or applications related to the scope of the journal (teaching/learning in physical education)? 2. Is relevant literature adequately critiqued and integrated into the arguments? 3. Are the arguments based on well-reasoned thoughts, rather than emotions? 4. Does the reasoning throughout the manuscript seem to be sound? 5. Are the conclusions consistent with the arguments developed or the empirical evidence reviewed? 6. Are practical implications of the arguments and/or ideas emphasized?

C. Guidelines for Reviewing Manuscripts the Second or Third Time:

1. All major concerns by reviewers and editors should be addressed in the first revision of a manuscript. 2. New major revisions should not be requested during the second or third revision of a manuscript unless a major change (e.g., new theoretical framework or revised analyses) requires further recommendations for changes. 3. Original reviewers should be employed in subsequent reviews unless the co-editor’s decision for the original manuscript is reject.

Guest Reviewers

Guest reviewers must have an earned doctoral degree specializing in sport pedagogy or related fields. Doctoral students (in the third year of their programs or beyond) may also participate as a  JTPE  guest reviewer under the supervision of their doctoral mentors.

The Metzler-Freedman Exemplary Paper Award

The Metzler-Freedman Exemplary Paper Award was established to highlight an article published in JTPE that exemplifies papers of the utmost excellence and innovation. The annual award is carefully chosen by a committee from all JTPE articles published within the calendar year. Selection of these awards are based on the significance of the work, quality of methods and writing, and the potential to have a positive impact on the field. Each year, the winners are presented and honored at the SHAPE America convention.

The Reviewer of the Year Award

The Reviewer of the Year Award is given annually to one or two reviewers—editorial board members and/or ad hoc reviewers—who have demonstrated excellence in their contributions to JTPE within the most recent year. Excellence is considered both in terms of editorial ratings of reviewer contributions and the number of reviewers completed for the journal. The Reviewer of the Year Award is presented annually at the JTPE Editorial Board meeting at the SHAPE America national convention.

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Classroom Q&A

With larry ferlazzo.

In this EdWeek blog, an experiment in knowledge-gathering, Ferlazzo will address readers’ questions on classroom management, ELL instruction, lesson planning, and other issues facing teachers. Send your questions to [email protected]. Read more from this blog.

Four Favorite Physical Education Instructional Strategies—Recommended by Teachers!

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This week’s “question-of-the-week” is:

What is the single most effective instructional strategy you have used when teaching physical education?

This post “wraps up” a longer series of questions and answers inviting educators from various disciplines to share their “single most effective instructional strategy.”

Five weeks ago, educators shared their recommendations when it came to teaching writing.

Four weeks ago, it was about teaching English-language learners.

Math was the focus three weeks ago.

Posts from two week’s ago were on science .

Last week’s post was on supporting students with learning differences .

Today’s contributors are Michael Gosset, Ed.D, Hunter Burnard , and Claudio Barbieri.

‘Movement Education’

Michael Gosset, Ed.D., is coordinator of physical education for Hostos Community College, CUNY. He has had published several articles and one book on Movement Education and Skill Themes:

If you define strategy as a plan or method, no single strategy can apply at both the kindergarten and 12 th grade levels, as they are so different. Other words to consider when describing how to teach at the various levels include approach and model.

Approaches/models I have used very successfully over decades, for the different levels, are Movement Education (which leads into the Skill Themes approach) for elementary school, and the Sport Education model for secondary school.

Movement Education, when taught using problem-solving methodology, allows children to be creative when “moving.” There is no single correct solution to a problem presented by the teacher such as how can you move on three parts of your body? The solutions are numerous. Movement Education is typically for kindergarten through 2 nd or 3 rd grade.

Once children know “how to move” successfully and understand movement concepts, the Skill Theme approach is a very appropriate approach to use with upper elementary. In the Skill Themes approach, various (sport) skills are repeated throughout the school year, enabling children to practice them more often. This is the opposite of the traditional approach called the Multi-Activity model where several sports are learned and played once yearly. Research has suggested that more students who are taught using the Skill Themes approach toward physical education enjoy it more than the Multi-Activity approach. This can lead to more children being active outside of school. More information on these approaches can be found in books.

The Sport Education model, for secondary students, has been used and researched for over 20 years. Its key for students is its “authenticity”—it makes learning sports fun for students because they not only participate but get to choose a role in its implementation, such as scorekeeper or statistician, just to name a couple. It is authentic because they learn the sport much more in depth than a traditional program of seasonally done sports.

For all levels, I have found teaching by indirect style to be the key to student learning and enjoyment. Another way of stating indirect style is, as previously mentioned, is problem solving. Presenting material in a way that encourages students to think for themselves is enriching and encourages “higher-order thinking skills,” or HOTS. It does indeed require more planning by the instructor, and experience in responding to student inquiries takes time. For example, if a student asks a question such as, “Can we…..,” the answer from the teacher can be, “Does that fit what I asked of you?” rather than “yes.” This is a change of paradigm and thinking for many instructors.

‘Differentiated Instruction’

Hunter Burnard grew up in Binghamton, N.Y. He played college lacrosse at Rutgers University before choosing to pursue a career in education. Hunter, who currently teaches at The Windward School in New York, and his wife are both teachers, and together they share a 1-year-old daughter, Shay:

As physical education teachers, our ultimate goal is to expose students to a variety of sports and game play in order for them to develop the knowledge, skills, and confidence to enjoy a lifetime of healthful physical activity.

Similar to classroom subjects, physical education classes are made up of students with a wide variety of backgrounds and ability levels. On top of this, I teach at a school for students with language-based learning disabilities. Because of this, I believe that the most effective instructional strategy that we employ is differentiated instruction among our students.

One way that we differentiate instruction in our class is through the teaching process, or how the material is presented and learned. For example, when introducing a new skill, I will verbally break down the requirements and strategies required to effectively execute the skill being taught. In addition, I will demonstrate the skill and often use our gymnasium projector to display a short video of what we are learning that day. We may use a video presentation early in the unit to teach a skill such as a wrist shot in hockey or something more conceptual such as route running in football.

In addition, we sometimes use video midway through a unit, prior to game play, to expose students to sports they are likely less familiar with such as European team handball or badminton. Regardless of the unit, by the time the student will need to use a skill in gameplay, they have heard it, seen it, and done it many times on their own or in a small group.

We not only differentiate instruction, but also we differentiate what we ask the students to produce in order to demonstrate understanding. This is critical to challenging students and keeping them engaged. If the goal of a soccer lesson is to introduce passing, I must differentiate my instruction for one student who has never played soccer and another who plays on a competitive travel soccer team. I may require the inexperienced student to simply practice completing 10 passes with a partner from a short distance while using the inside of their foot.

On the other hand, to challenge the more experienced soccer player and to keep them engaged, I would require that student to use their nondominant foot and to pass at a greater distance with accuracy. Ultimately, although we are assessing skill, we are most concerned with effort in our classroom. Therefore, although the students have different ability levels and are demonstrating different difficulty levels of the same skill, I am most concerned with their effort in completing the assignment.

Lastly, we provide opportunities throughout each class for students to raise their hand and volunteer information as another way to demonstrate understanding of the concept or skill being taught that day. This is particularly important for students who understand concepts and strategies required to be successful but struggle to physically complete a task as successfully as they may like because of limited skill or inexperience.

Differentiated instruction undoubtedly requires some additional work while executing a lesson, but I think it is essential to implementing an effective physical education curriculum. The great thing about physical education is that while exposing students to a wide variety of activities, we as educators can learn about students likes, dislikes, skills, and ability levels in a broad range of topics and activities. Differentiating instruction accordingly is the most effective way to maximize the physical education experience for all students.

‘Multisensory’

Claudio Barbieri has been a physical education teacher for nine years, with experience teaching grades 1-12. He currently teaches at The Windward School in New York. He received his bachelor’s degree in physical education from Manhattan College and a master’s degree in health education from Lehman College:

I have been a physical education teacher for nine years in N.Y.C. in both the public and private school settings. There are many strategies we use as educators, but the one I find most effective is a multisensory approach.

This strategy is helpful for all students. The most important thing for me is that students learn the fundamentals of the skill, have fun, and develop confidence throughout the lesson. The multisensory strategy allows students to experience success differently as well. For example, during our basketball unit, one student might feel they were successful if they were able to make one shot using proper form and technique during the unit. However, another student might feel they were successful if they were making their shots more consistently using proper form and technique. In both situations, each student would have the knowledge to go back to the fundamentals they were taught regardless of what kind of learner they are.

The multisensory strategy is a powerful way to teach students in a physical education setting because it covers the needs of all types of learners. This strategy is also a great way for students to develop confidence in volunteering to demonstrate or explain an activity or skill.

Since I use this strategy with all my units and lessons, we have a greater number of students willing to demonstrate or explain an activity or skill as the school year progresses. I would encourage teachers to try this strategy with their classes because everyone learns differently. Lastly, the multisensory strategy will encourage you to become a better educator because you will have to think of all the ways to present your lesson to the class while keeping in mind the variety of ways students learn and retain information.

Thanks to Michael, Hunter, and Claudio for their contributions!

Please feel free to leave a comment with your reactions to the topic or directly to anything that has been said in this post.

Consider contributing a question to be answered in a future post. You can send one to me at [email protected] . When you send it in, let me know if I can use your real name if it’s selected or if you’d prefer remaining anonymous and have a pseudonym in mind.

You can also contact me on Twitter at @Larryferlazzo .

Education Week has published a collection of posts from this blog, along with new material, in an e-book form. It’s titled Classroom Management Q&As: Expert Strategies for Teaching .

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Kids need physical education – even when they can’t get it at school

College of Education Associate Dean for Research and Innovation and Professor of Physical Education, University of South Carolina

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When I noticed my 12-year-old son was spending about seven hours a day doing his school work online due to the COVID-19 pandemic, I immediately became concerned. As a researcher who focuses on how to get kids to be more physically active , I knew my son and his classmates were spending too much time sedentary.

Being physically active is good for everyone’s physical and mental health, including children of all ages and abilities.

Kids who are more physically active tend to get better grades and develop the self-confidence that can empower them to succeed later in life.

For people with disabilities, physical activity can help them gain independence .

A summer slide in physical activity

The arrival of summer vacation might allay concerns parents have about their children being too sedentary. I remember summer vacation as a welcome break from sitting in school and being stuck indoors. However, the reverse may be true for many kids today.

In the U.S., a study of 18,170 young children found that the share of children who were obese rose from 8.9% to 11.5% between kindergarten and second grade. The increase generally occurred over the summer, not when kids were in school.

Researchers think a lack of structured summertime activities can cause kids to make unhealthy choices. This idea is bolstered by a review of 37 studies that found children were less active on weekends than on school days, and research showing that kids spend more time using screens in the summer than during the school year.

One hour a day – an elusive goal

The Department of Health and Human Services recommends that school-aged children and adolescents spend at least a total of one hour each day running, biking or doing another physical activity. Yet, according to the Centers for Disease Control and Prevention , about 1 in 4 kids between the ages of 6 and 17 were meeting that recommendation prior to the pandemic.

Even children who participate in organized sports may not be obtaining the prescribed 60 minutes of activity per day. One study found that children in flag football leagues spent only 20 minutes exercising during team practices. This finding is fairly consistent across other sports, such as soccer and basketball , where no more than about half of practice time was spent exercising.

The level of physical activity plummets when kids reach middle school, and it doesn’t make much of a difference whether they’re on teams or not. A study in San Diego found that kids between 11 and 14 years old spent a total of seven minutes less on physical activity , as compared to children between 7 and 10 years old, during sport practices.

Meanwhile, children and adolescents spend as much as eight hours daily doing things like watching TV, using smartphones and playing video games.

School physical education – the pill not taken

When it comes to promoting physical activity, researchers have referred to physical education as “ the pill not taken .” Currently, only Oregon and the District of Columbia have policies that require schools to provide the nationally recommended amount of time for PE – 150 minutes weekly for elementary grades and 225 minutes for middle and high school students. Also, more than half of the states have loopholes that let high school students skip PE.

Overall, most school systems weren’t doing enough to keep kids fit before COVID-19 ushered in months of makeshift remote learning. The CDC gave schools a grade of D- for their efforts on that front.

In short, the vast majority of kids need to spend more time being active both in school and at home. Additional time spent in PE class increases students’ ability to learn the skills to stay active as adults.

What kids need from PE

Physical education provides kids with more than just exercise, which is why activities like marching band and even team sports are, in my view, a poor substitute.

In elementary school, PE should mainly support the development of fundamental motor skills, such as jumping, kicking, throwing and catching, which are essential for a wide range of activities, such as most team sports, dance and gymnastics. Children who have mastered these skills are more physically active than those who haven’t.

Middle and high school PE programs should focus on keeping kids motivated to stay active. Because adolescents are more motivated to be physically active when they feel like they’re in control of their learning, giving them a say in terms of what they do matters. Since different kids have different interests, the PE curriculum should span not only team sports, but also activities that require fewer participants, such as tennis and golf.

Students at all levels of instruction should have opportunities to develop their physical fitness , especially their aerobic endurance, muscular strength and flexibility.

What parents can do

Dozens, maybe hundreds, of online resources are devoted to keeping kids active and fit when they aren’t in school. However, I’ve found that few are backed by research and that most were not developed by professional PE educators.

Rather than scour the internet for ideas, parents of elementary students should play games with their children that incorporate fundamental motor skills. Throwing and catching a beanbag, striking a balloon with a paddle and kicking a ball are all helpful.

Encouraging children to dance and do some basic tumbling will help them improve their balance .

Parents of middle and high school students should encourage their kids to try activities they might enjoy and continue into adulthood, such as running, hiking, biking and – when facilities are available – racquetball. Try to encourage them by participating yourself and being a physically active role model.

Whenever possible, parents should support their children’s activity interests by assisting with transportation, buying equipment and planning family outings to parks and local events like fun runs.

Parents should also help their children learn to track and manage their personal fitness. Wearable fitness trackers like Fitbits are a helpful tool. Kids can use these to set daily step goals and monitor progress.

Families also can regularly try new activities that make fitness fun. For example, to work on aerobic endurance, try jumping rope or dancing. Instead of using weights to build muscular strength, go kayaking or rock climbing, or use resistance bands at home. Yoga, pilates and tai chi are great for developing flexibility.

Just remember this: Physical activity is a behavior and physical fitness is a condition. Neither are synonymous with physical education but a good PE program will help bring about both.

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Amanda Amtmanis, an elementary physical education instructor in Middletown, Connecticut, handed out cards with QR codes to a class of third graders, and told them to start running.

The kids sprinted off around the baseball field in a light drizzle, but by the end of the first lap, a fifth of a mile, many were winded and walking. They paused to scan the cards, which track their mileage, on their teacher’s iPad and got some encouragement from an electronic coach — “Way to run your socks off!” or “Leave it all on the track!”

A boy in a red Nike shirt surged ahead, telling Amtmanis his goal was to run 5 miles. “Whoa, look at Dominic!” another boy exclaimed.

“We don’t need to compare ourselves to others,” Amtmanis reminded him.

The third graders finished a third lap, alternating running and walking, and were about to start on a scavenger hunt when the rain picked up, forcing them inside. Amtmanis thanked her students for their willingness to adjust — a skill many of them have practiced far more often than running these past 18 months.

The full impact of the pandemic on kids’ health and fitness won’t be known for some time. But it’s already caused at least a short-term spike in childhood obesity Rates of overweight and obesity in 5- through 11-year-olds rose nearly 10 percentage points in the first few months of 2020.

Amtmanis’ “mileage club,” which tracks students’ running, both in and out of school, and rewards them with Pokémon cards when they hit certain targets, is an example of how PE teachers around the country are trying to get kids back in shape.

But inclement weather isn’t the only thing PE teachers are up against as they confront what might be called “physical learning loss.” Physical education as a discipline has long fought to be taken as seriously as its academic counterparts. Even before the pandemic, fewer than half the states set any minimum amount of time for students to participate in physical education, according to the Society of Health and Physical Educators (SHAPE), which represents PE and health instructors.

Now, as schools scramble to help kids catch up academically, there are signs that PE is taking a back seat to the core subjects yet again. In some California schools, administrators are shifting instructional minutes from PE to academic subjects — or canceling class altogether so PE teachers can sub for classroom teachers; in others, they’re growing class sizes in the gym, so they can shrink them in the classroom.

Meanwhile, innovative instructors like Amtmanis, who has worked in her district for more than 20 years, are struggling to get their ideas off the ground. Over the summer, the principal of Macdonough Elementary, one of two schools where Amtmanis teaches, approved her request to participate in another running program called The Daily Mile, in which kids walk or run 15 minutes a day during school hours.

Daily running breaks “boost attentiveness, which has positive effects on academics,” Amtmanis argued.

But two weeks into the school year, not a single teacher had bought into the idea.

“The issue is their packed schedule,” Amtmanis said.

Last year, many schools conducted gym class remotely, with students joining in from their bedrooms and living rooms.

The online format presented several challenges. Many students lacked the equipment, space, or parental support to participate fully. And many instructors grappled with how to teach and assess motor skills and teamwork online.

Though instructors found creative ways to keep students moving — substituting rolled-up socks for balls, and “disguising fitness” in scavenger hunts and beat-the-teacher challenges — they still fretted that online gym wasn’t giving students the same benefits as in-person classes.

Compounding their concern was the fact that many students were also missing out on recess and extracurricular sports.

In a March 2021 survey conducted by the Cooper Institute, maker of the popular FitnessGram assessments, close to half the PE teachers and school and district administrators responding said their students were “significantly less” physically active during their schools’ closure than before it.

Schools that reopened last year faced their own set of challenges, including bans on shared equipment that made even a simple game of catch impossible. Schools that were open for in-person learning were also much more likely to cut back on PE instructional time, or eliminate it altogether, the survey found.

The consequences of these reductions in physical activity are hard to quantify, especially since many schools suspended fitness testing during the pandemic and have yet to resume it, but some PE teachers say they’re seeing more kids with locomotor delays and weaker stamina than normal.

“The second graders are like first graders, and some are even like kindergarteners,” said Robin Richardson, an elementary PE instructor in Kentucky. They can jump and hop, she said, but they can’t leap. They’re exhausted after 20 seconds of jumping jacks.

An unusually high number of Richardson’s first graders can’t skip or do windmills. Some lack the spatial awareness that’s essential to group games.

“They don’t know how to move without running into each other,” she said.

Other instructors are seeing an increase in cognitive issues, such as difficulty paying attention or following directions, particularly among kids who remained remote for most or all of last year.

Kyle Bragg, an elementary PE instructor in Arizona, has seen kids sitting with their backs to him, staring off into space when he’s talking. “I say ‘Knees, please,’ so they spin around to face me,” he said.

And some PE teachers say their students’ social-emotional skills have suffered more than their gross motor skills. “They forgot how to share; how to be nice to each other; how to relate to each other,” said Donn Tobin, an elementary PE instructor in New York.

PE has a key role to play in boosting those skills, which affect how kids interact in other classes, said Will Potter, an elementary PE teacher in California.

“We’re uniquely situated to handle the social-emotional needs that came out of the pandemic, in a way classroom teachers are not,” Potter said.

Amtmanis, for her part, worries about her students’ mental health. She sees the little signs of strain daily — the kid who got upset because he couldn’t pick his group, for example, and the one who was distressed that his Mileage Club card had gotten mixed up in the front office.

“Their emotional reserves are low,” she said.

Yet not all instructors are reporting drops in their students’ fitness and skill development. Teachers in some middle- and upper-income districts said they haven’t noticed much of a change at all. In some communities, families seemed to spend more time outdoors.

“We saw the skyrocketing sale of bicycles, we saw families going for walks,” said Dianne Wilson-Graham, executive director of the California Physical Education and Health Project.

But in Title I schools like Macdonough, where more than half the students are low-income, some kids didn’t even have access to a safe place to exercise or play during school closures.

“Not only are they not in soccer leagues, but sometimes they don’t even have a park,” Amtmanis said.

Amtmanis came up with the idea of doing the Daily Mile after spring fitness tests revealed drops in her students’ strength, flexibility and endurance.

But many schools still aren’t sure how much physical learning loss their students have experienced as a result of the pandemic. Most schools pressed pause on fitness testing last year, and some elementary-school instructors are reluctant to restart it. They say the tests aren’t valid with young children, even in ordinary times, and argue the time they take could be better spent on Covid catch-up.

Andjelka Pavlovic, director of research and education for the Cooper Institute, said its tests are scientifically proven to be valid for students who are 10 and up, or roughly starting in fourth grade.

Fitness testing requirements vary by state, county or even district. Some states specify how often students must be tested; others leave it largely to the teacher.

Bragg, the Arizona teacher, said he has put testing “on the backburner” because “right now it’s not at the forefront of what’s important.”

Richardson said she is avoiding testing because she doesn’t want to use up precious instructional time or demoralize her students. “I want my kids to enjoy movement,” she said. If they perform poorly on the tests, “they may not feel as strong.”

In Connecticut, where schools are required to test fourth graders’ fitness annually, Amtmanis approached testing cautiously last year. She didn’t want to embarrass her students, so she made it into a series of games.

Instead of Sit-and-Reach, they had a “flexibility contest,” in which kids broke into teams for tag then had to perform stretches if they were tagged. She measured the distances stretched with curling ribbon, tied the ribbons together, and attached a balloon to the end. The team whose balloon soared the highest won fidget putty.

Pushups became a Bingo game, with the center space representing pushups.

“My goal was to get through it without ever using the words ‘fitness” or ‘testing,’” she said.

As the pandemic drags on, some instructors are taking a similar approach to fitness remediation and acceleration.

Bragg likes a warmup called “ Touch Spots ,” in which first graders listen as the instructor reads off the name of a color, then run and touch a corresponding dot on the floor. It works on reaction time, cardiovascular endurance, spatial awareness and sequencing — but the kids don’t know that.

“Students are having so much fun that they don’t realize how much fitness they are doing,” Bragg said.

Differentiation — tailoring instruction to meet individual students’ needs — has become even more essential, with former remote learners often lagging behind their in-person peers, Bragg said.

When playing catch, for example, he offers his students different sized balls — the smaller ones are more challenging.

Potter, the California teacher, spent the first two weeks of school teaching his students how to connect with their partners, stressing the importance of eye contact and body language.

“When you’re on Zoom, you look at the camera to make eye contact,” he said. “It’s a very different environment.”

Bragg reminds his students how to include kids who are standing on the sidelines, modeling excited body language and tone of voice. Lately, he’s noticed that kids who were remote last year are being excluded from groups.

“Social interaction needs to be practiced, just like how to throw a ball,” he said.

Richardson, the Kentucky PE teacher, is trying to build up her students’ stamina gradually, through progressively longer intervals of exercise.

But she works in a school with pods, so she sees each group of kids for five consecutive days, every third week. The two weeks in between, she has to hope that teachers will provide recess and “movement breaks.” She’s trying to get them to give kids breaks “when they get glassy-eyed and frustrated.”

Recently, Richardson was at a staff training session at which depleted teachers were “popping candy in the back.” When she raised her hand and requested a break in the training, her colleagues cheered. She told them to remember how they felt when their students return to the building.

“I always say, ‘If your bum is numb, your brain is the same,’” she said.

Convincing classroom teachers to set aside more time for movement can be challenging, though. As students return from months of online learning, teachers are under enormous pressure to get them caught up academically.

Kate Cox, an elementary and middle-school PE teacher in California, wishes schools would “realize what they’re missing when they cut PE because of learning loss in other areas.” Physical education is “readying their minds and bodies to be more successful in other areas,” Cox said.

Terri Drain, the president of SHAPE, argued that schools fail students when they treat physical learning loss as less serious than its academic counterpart.

“In the primary grades, children develop fundamental motor skills, such as throwing, catching, running, kicking and jumping,” she said. Unless schools commit to helping kids catch up, “the impacts of this ‘missed learning’ will be lifelong.”

In Connecticut, Amtmanis hasn’t given up on convincing teachers to carve out time for the Daily Mile. She recently sent them a list of suggestions on how to fit 15 minutes of running into the day, including by incorporating it as an active transition between academic blocks.

“While it may seem like there aren’t minutes to spare,” she wrote, “the energizing effect of the active transition should result in more on-task behavior and more efficient working.”

In the meantime, Amtmanis plans to keep using the mileage club to motivate her students to run and to monitor their progress.

“I don’t want to call attention to the fact that not everyone is fit,” she said. “This is an unobtrusive way to keep the data.”

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Supporting Physical Education in Schools for All Youth

• Policy Statements and Advocacy
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• Proposed Policy Statements
• Date: Oct 26 2021
• Policy Number: 20211

Key Words: Physical Activity, Education, School Health, Obesity

Abstract This policy statement provides scientific evidence that schools are unique places where children should be engaged in physical activity. However, most school policies and programs are not supportive of physical activity in the school day, specifically physical education. Considering that 30.4% of youth are overweight or obese and that 76.8% do not meet the daily physical activity recommendations, and considering the benefits of physical activity with respect to increased ability to concentrate and learn, it is of the utmost importance to incorporate policies and programs that facilitate healthy engagement in physical activity in schools. Marginalized youth from low-income families, communities of color, immigrant communities, and others are disproportionately impacted by lack of supportive policies and programming. This policy statement calls for comprehensive and cooperative actions from the public health community, schools, administrators, researchers, and community members to increase physical activity opportunities through physical education in order to engage youth in at least 60 minutes of physical activity daily.

Relationship to Existing Policy Statements 

• APHA Policy Statement 20137: Improving Health and Wellness through Access to Nature
• APHA Policy Statement 20172: Supporting the Updated National Physical Activity Plan
• APHA Policy Statement 201515: The Role of Health Education Specialists in a Post-Health Reform Environment
• APHA Policy Statement 20079: Building a Public Health Infrastructure for Physical Activity Promotion
• APHA Policy Statement 9709: Promoting Public Health Through Physical Activity
• APHA Policy Statement 20044: Creating Policies on Land Use and Transportation Systems that Promote Public Health
• APHA Policy Statement 20058: Supporting the WHO Global Strategy on Diet, Physical Activity and Health
• APHA Policy Statement 200619: Urgent Call for a Nationwide Public Health Infrastructure and Action to Reverse the Obesity Epidemic
• APHA Policy Statement 201514: Building Environments and a Public Health Workforce to Support Physical Activity Among Older Adults
• APHA Policy Statement 20121: Supporting the National Physical Activity Plan
• APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health

Problem Statement Obesity is an important health issue among children in the United States. According to the 2019 National Health and Nutrition Examination Survey, 16.1% of U.S. youth are overweight and 19.3% are obese.[1] Moreover, racial, socioeconomic, and gender disparities exist in terms of risk factors associated with being overweight or obese. The chronic disease burden is consistent with the disproportionately high percentages of overweight and obese youth in racial minority and socioeconomically disadvantaged populations. According to data from the 2019 Youth Risk Behavior Surveillance System (YRBSS), 37.7% of Black youth and 38.8% of Hispanic youth are overweight or obese, as compared with just 27.7% of White youth.[2]

P hysical inactivity is a significant risk factor for obesity and other chronic conditions.[3] As the proportion of students who are overweight or obese has increased, so has inactivity. Empirical evidence suggests that physical activity may be used as a standalone strategy to decrease adiposity among children.[4] It is recommended that school-aged children and adolescents (6–17 years of age) engage in 60 minutes of physical activity seven days per week.[5] According to data from the 2019 YRBSS, 76.8% of youth do not meet the recommended amounts of physical activity.[2] The same data set indicates that adolescent girls, in particular, are at a higher risk for being inactive as they age; 84.6% of girls do not meet the physical activity guideline of 60 minutes per day seven days a week, as compared with 69.1% of boys.[2] In addition, inactive youth are more likely to be inactive as adults.[6] Starting physical activity early is essential to prevent inactivity in adulthood and older adulthood.

Physical activity provides benefits beyond physical health. For example, it is associated with a reduced risk for depression.[7] Trends for contemplating and making a plan for suicide are increasing among White, Hispanic, and Black youth, and there are racial and ethnic disparities in terms of mental health challenges among youth.[5] In 2019, 40.0% of Hispanic youth reported persistent feelings of sadness or hopelessness, as compared with 36.0% of White youth and 31.5% of Black youth.[5]

In addition to the long-term health benefits of child physical activity, there are numerous academic-related benefits, which the body of evidence continues to expand.[8] Extensive research has demonstrated strong positive correlations between physical activity and higher levels of physical fitness and academic achievement, educational attainment, academic performance, and brain functioning.[8–10] In fact, physical activity participation has both intermediate and long-term benefits with respect to academic performance. Research has shown that, immediately following engagement in physical activity, children have improved concentration on classroom tasks, which may potentially enhance learning.[8]

It is recommended that schools provide 150 minutes of instructional physical education for elementary school children and 225 minutes for middle and high school students per week for the entire school year.[11] However, only Oregon and the District of Columbia have requirements that meet the recommendations for minutes of physical education.[12] Physical education requirements notably decrease after the fifth grade, which aligns with significant decreases in physical activity in youth. Only 8.7% of schools require physical education for 12th grade, as compared with 45.1% of schools for fifth grade.[13]

The lack of universal physical education requirements at all grade levels and the lack of funding dedicated to physical education facilitate inactivity. The median school physical education budget in the United States is just $764 per year,[12] which may further hinder schools from meeting physical education recommendations. Ohinmaa and colleagues suggested that grants, donations, and fundraising account for about half of all funding for school health.[14] Improving physical education policies nationwide has the potential to reduce overall health care costs by $60.5 million within 10 years.[15]

Students who attend physical education in school are two to three times more likely to be physically active outside of school and nearly twice as likely to be active in adulthood.[16] Furthermore, physical education has been shown to be an opportunity for students to gain many of their recommended minutes of physical activity, but many students do not attend or participate in these classes.[13] According to 2019 YRBSS data, about half of high school students attend physical education classes one or more days per week.[2] Therefore, targeting middle and high schools is uniquely important because a significant drop in physical education attendance and physical activity participation occurs between the seventh and 12th grades.[11]

Evidence-Based Strategies to Address the Problem   Youth spend a significant portion of their time at school[17]; therefore, schools are one of the most important places for physical activity interventions.[18] According to the Society of Health and Physical Educators, schools should require physical education for students in kindergarten through grade 12.[19] Specifically, all students within secondary school (which includes middle school and high school) should achieve 225 minutes of physical activity per week, while students in primary school (which includes elementary school) should achieve 150 minutes per week.[19]

Current evidence-based strategies to increase physical activity among youth are described below.

Improving school-based physical education: According to the Community Preventive Services Task Force (CPSTF),[20] enhanced school-based physical education involves changing the curriculum and coursework for K–12th-grade students to increase the amount of time students spend engaging in moderate to vigorous physical activity (MVPA) during physical education classes. Enhanced school-based physical education is defined as increasing the amount of time students spend completing MVPA during physical education classes to at least 50% of class time.[20] The CPSTF specifically recommended improving physical education teaching strategies by (1) incorporating modified games and substituting sedentary games with active games and (2) including physical education lesson plans that incorporate fitness and circuit training activities.[20]

Lonsdale and colleagues highlighted effective strategies to increase MVPA, which included teacher professional learning focusing on class organization, management, and instruction and supplementing the usual physical education lessons with high-intensity activity (i.e., fitness infusion).[21] A systematic review of 14 studies showed that students who participated in enhanced school-based physical education classes engaged in 24% more MVPA.[21] Also, groups that received enhanced school-based physical education spent on average 53% of their time engaged in MVPA.[21] In addition, Zhou and Wang found that team games were reported to accumulate the most MVPA time, with movement-based activities (such as gymnastics and dance) having the highest amounts of MVPA and knowledge-based activities (i.e., lesson-based instruction) having the lowest amounts.[22] Implementation of enhanced school-based physical education aligns with the Healthy People 2030 objectives, which aim to increase the proportion of adolescents who meet current federal physical activity guidelines for aerobic physical activity and muscle-strengthening activity.[23]

It is important that physical education classes be taught by state‐licensed or state‐certified teachers who are endorsed to teach physical education. In a meta-analytic review, Hollis and colleagues found that youth were engaged in MVPA for an average of 44.8% of lesson time.[24] Low MVPA levels in physical education lessons could be the result of pedagogical characteristics often observed in typical lessons, such as stopping physical activity to provide instruction, observing demonstrations related to the activity, or organizing equipment or student groups.[25] An examination of time allotment in terms of lesson context revealed that 30% of lesson time was spent in game play, 29% in fitness, 20% in classroom management, 9% in knowledge-related activities, and 5% in skill-related activities.[15] Similar results were found in a study by Powell and colleagues in which the average length of physical education lessons was 35.3 minutes, with only 15 minutes of MVPA during physical education.[26] Results further demonstrated that 34% of the lesson was spent standing and 21.7% was spent sitting, with time sitting being directly linked to knowledge attainment.[26] 

In conclusion, a significant proportion of physical education instruction time is spent on classroom management, instruction, and transitional periods. While these periods are necessary, they detract from the overall time youth spend participating in MVPA. It is, therefore, recommended that all physical education courses be taught by qualified individuals who have received formal training in physical education pedagogy. SHAPE America has specifically recommended that physical education be taught by an endorsed state‐licensed or state‐certified teacher.[11] This educational licensure or certification requirement would ensure that the physical education curriculum used in schools is appropriate and maximizes the time students spend engaging in MVPA while also aligning with national and/or state physical education standards for K–12 physical education.[11] 

Increasing the frequency of physical education: Scientific evidence has shown that increasing the frequency of physical education can improve overall physical activity among youth. Research indicates that only 25.9% of high school students attend physical education classes five days per week.[5]  Findings from the School Health Policies and Practices Study showed that less than 4% of elementary and middle schools require physical education or similar activity every day throughout the school year.[18] Moreover, less than 9% of middle schools require physical education at least three days per week.[18] Physical education instruction for high school students decreased from 29.9% in 2017 to 25.9% in 2019.[5]

The benefits of regular physical activity are well documented and include improvements in bone and muscle development, cardiorespiratory fitness, and weight control; reduced symptoms of depression and anxiety; and reduced risks of heart disease, cancer, type 2 diabetes, and hypertension.[3] Research has demonstrated that physical activity throughout the school day is associated with better school performance.[8] Healthy People 2030 objectives highlight the importance of increased physical activity through improved physical education in both public and private school systems. Specifically, the Educational and Community-Based Programs workgroup aims to increase the proportion of adolescents who participate in daily school-based physical education.[7]

Reduction or removal of waivers, substitutions, and exemptions for physical education: Another important strategy to increase school-based MVPA is the reduction or removal of waivers, substitutions, and exemptions for physical education. According to the Shape of the Nation 2016 report, 30 U.S. states allow student exemptions from physical education classes, and 31 states allow students to substitute activities such as marching band, cheerleading, drill team, or intramural sports for physical education credit.[12] SHAPE America issued a position statement according to which school districts and schools should not allow waivers or exemptions from physical education class time or credit requirements.[11] Specifically, SHAPE firmly asserted that all students should be required to complete physical education courses and that state, district, and school policies should not allow substitutions, waivers, or exemptions for physical education courses, class time, or credit requirements. By allowing waivers, substitutions, and exemptions for physical education, schools and districts eliminate opportunities for students to be active at a time when physical activity levels are at an all-time low among youth.[11] As mentioned, schools offer a unique setting to teach children the value of physical activity as well as a structured, supervised environment in which children can learn the necessary skills to encourage lifelong physical activity.[11]

Culturally tailored physical education: Multiple organizations have reported the need to ensure culturally tailored physical education for all populations, especially marginalized populations such as minority racial, ethnic, and cultural groups; girls and women; refugees; people experiencing homelessness; LGBTQ+ (lesbian, gay, bisexual, transgender, queer or questioning) populations; and others.[27,28] The United Nations Educational, Scientific and Cultural Organization’s Guidelines for Policy-Makers on Quality Physical Education stated the need for and importance of providing physical education for minority groups. According to the guidelines, (1) curricula should be flexible and adaptable for all groups, (2) teachers should be professionally qualified and capable of providing physical education for all students, and (3) school policies and practices should provide appropriate infrastructure, faculties, equipment, and teaching material for all students.[28]

Lastly, it is recommended that teachers have access to resources such as community health workers who can provide culturally specific guidance on physical education. Community health workers are particularly effective because of the cultural and linguistic connections they have with the communities they serve.[29] Providing culturally appropriate physical education may increase physical activity,[30] decrease obesity,[31] and improve the overall health of minority groups by increasing social support, promoting healthy lifestyles, and increasing knowledge of disease prevention.[32]

Adaptive physical education: According to the Physical Activity Guidelines for Americans, children and adolescents with disabilities are more likely to be inactive than those without disabilities.[7] It is recommended that children and adolescents with disabilities still aim to meet the key guideline of 60 minutes of physical activity every day when possible. If youth are unable to participate in the physical activities or durations needed to meet the key guidelines, it is recommended that they be as active as possible and avoid being inactive.[7]

Youth with disabilities should work with health care professionals or physical activity specialists to learn about the types and amounts of physical activity appropriate for them.[7] The Adapted Physical Education National Standards were developed to ensure that physical education for children with disabilities be delivered by a qualified adapted physical educator. According to these standards,  physical education teachers should use sound teaching practices to ensure the inclusion and representation of all skill and ability levels.[33] Specifically, master physical educators should be well prepared to provide knowledge acquisition as well as physical activity opportunities for all abilities to create active and healthy lifestyles for all students. In addition, the standards outline high expectations for a physically active lifestyle. Lastly, it is expected that master physical educators will maintain a stimulating, productive learning environment that holds all students to the highest expectations for a physically active lifestyle.[33]

Conclusion: In conclusion, schools are the ideal and recommended setting for the promotion of physical activity among youth, and physical education is the primary vehicle through which to achieve this objective in schools.[34] Improving the quality and quantity of physical education courses will give youth more opportunities to attain the recommended amount of physical activity each day. Reducing physical education waivers would ensure that youth are not exploiting a loophole in the system. Advocating for culturally tailored physical education and adaptive physical education would foster an inclusive environment in which all children are able to be physically active and healthy.

Opposing Arguments/Evidence  Few would disagree that physical activity and time spent engaged in physical education are important for youth development and overall health. The primary opposing arguments tend to stem from the poorly designed physical education curriculum and the time taken away from other subjects amid increased pressure to raise standards and scores in subjects such as math, science, and English. As a result, time allocated to physical education and the perceived importance of physical education lessons have been reduced.  However, there is a substantial amount of evidence that physical activity can help improve academic achievement, including overall grades and standardized test scores.[34] In a systematic review of 43 articles and 50 studies, the Centers for Disease Control and Prevention (CDC) determined that physical activity has a positive impact on cognitive skills, attitudes, and academic achievement.[34] Specifically, physical activity enhanced concentration and attention and improved classroom behavior.[34] The review also showed that increasing time during the school day for physical activity does not appear to take away from overall academic performance.[34]  Therefore, the CDC recommended that schools increase the amount of time students spend in physical education or consider adding components to increase the quality of physical education classes.[34] As highlighted in the evidence-based strategies to improve school-based MVPA, the CPSTF recommended use of enhanced physical education, including improved physical education teaching strategies, by incorporating modified, more active games and physical education lesson plans that involve fitness and circuit training activities.[20]

Alternative Strategies Enhancing, encouraging, and maintaining physical education class duration and quality are vital to the health and well-being of children, particularly in terms of their physical activity behaviors. However, there are several alternative strategies to increase the physical activity of youth that should be considered in conjunction with retaining the importance of physical education.

Before- and after-school physical activity programs: According to the World Health Organization, after-school activities are a key avenue to supplement youth MVPA levels.[35] After-school physical activity could include physical activity clubs, intramural programs, informal play on school grounds, physical activity in school-based before- and after-care programs, and interscholastic sports.[18] Mayorga-Vega and colleagues found that physical activity that took place after school hours achieved 36% of the recommended 60 minutes of MVPA per day.[36] However, adolescents still reported a higher level of MVPA during physical education classes than during school recess and after-school programs.[36]

Only about 26% of the nation’s public and private schools provide access to their physical activity spaces and facilities for all individuals outside of normal school hours. In addition, a steady decline has been observed in provision of access to physical activity facilities during nonschool hours.[37] Therefore, schools can further encourage physical activity by opening up their facilities for community use.[18]

Increasing active transportation to and from school: According to the CPSTF, walking or bicycling to and from school provides children and adolescents with an opportunity to be physically active most days of the week.[38] Interventions such as the Safe Routes to School program could increase active transportation to and from school and reduce pedestrian and bicycle injury rates. However, there is not enough evidence to show that school travel leads to increases in students’ overall daily physical activity.[38]

Recess: Recess is defined as a regularly scheduled period during the school day for physical activity and play that are monitored by trained staff or volunteers.[13] Recess has been directly related to increased physical activity, improved memory, improved attention, improved concentration, decreased classroom disruptive behavior, improved social and emotional development, and academic achievement.[8,39–41] It is recommended that elementary, middle, and high school students have a minimum of 20 minutes of daily recess.[39] The CDC has further recommended that recess and physical education be separate, distinct physical activity opportunities, which creates separate times for skill acquisition (physical education) and active play (recess).[39] Also, the CDC has recommended that schools provide students with adequate, designated, and safe spaces, facilities, equipment, and supplies for both indoor and outdoor recess (e.g., playground markings, physical activity zones, activity cards).[39] Lastly, students should not be excluded from recess for disciplinary reasons or academic performance because such practices promote negative reinforcement.[39]

Classroom-based physical activity: Classroom-based physical activity, including single physical activity sessions, may increase student attention, concentration, and memory; increase motivation and enjoyment of learning; and reduce behavior issues.[8,40] Classroom-based physical activity integration may include physically active lessons, physical activity before a test, physical activity breaks, energizers, brain boosters, and active classrooms (a teaching technique that intentionally blends physical activity into academic lessons to satisfy the learning outcomes of the classroom without sacrificing time spent engaging in physical activity).[8,40,42] Further guidance by the CDC and other national organizations includes providing teachers with ongoing professional development to integrate physical activity into planned academic instruction as a means of reinforcing academic concepts.[40]

Action Steps Increasing physical activity among school-aged children is a vital investment in the health and well-being of youth in the United States. Increasing physical activity at this critical age has the potential to build healthier, happier young adults. Schools should support physical activity through culturally appropriate, high-quality physical education. Schools; local, state, and federal education agencies; public health departments; policymakers; and researchers should address the following objectives relevant to public health priority setting in order to advance school-based physical activity programming and activities:

• Federal agencies should develop national policies on physical education that are consistent with the larger national strategies to increase physical activity among youth.
• Federal and state governments should increase funding for schools to implement high-quality physical education programming
• State and local education departments should improve physical education requirements to provide the opportunity for 60 minutes of MVPA each school day.
• Policymakers at state and local education departments should be made aware of the importance of physical education provided by schools.
• Schools should require that all physical education teachers be appropriately credentialed to deliver culturally appropriate, high-quality physical education.
• Schools should solicit involvement and expertise from state and local public health departments and physical activity researchers on culturally specific, evidence-based strategies to improve school-based physical education.
• Principals and superintendents of schools should develop action plans to improve physical education for all of their students. Youth should have the opportunity to engage in 60 minutes of physical activity during the school day.
• Principals and superintendents should reduce or eliminate policies allowing waivers for physical education. Waivers should be considered on a case-by-case basis.
• Schools and school districts should engage in collaborative efforts to share the results of successfully implemented physical education programs.
• Schools and researchers should collaborate in studying physical activity among diverse youth who have been traditionally understudied and systematically underserved. Furthermore, researchers should be encouraged to develop innovative programs for youth in school settings that promote physical activity for all.
• Greater diversity in programming should be implemented in schools so that youth can be exposed to a variety of activities that those of all abilities and cultures might enjoy.
• Youth, families, community members, and local organizations should advocate to their school districts and legislative bodies for culturally appropriate, high-quality physical education in their local schools.
• Public health departments should partner with and support physical education teachers and programs. This support should include school-based physical activity in community health assessments and community health improvement plans highlighting the importance of physical activity in preventing chronic disease and providing mental and cognitive benefits.

References 1. Fryar CD, Carroll MD, Afful J. Prevalence of overweight, obesity, and severe obesity among children and adolescents aged 2–19 years: United States, 1963–1965 through 2017–2018. Available at: https://www.cdc.gov/nchs/data/hestat/obesity-child-17-18/overweight-obesity-child-H.pdf. Accessed October 20, 2021. 2. Centers for Disease Control and Prevention. 2019 Youth Risk Behavior Survey Questionnaire. Available at: www.cdc.gov/yrbs. Accessed October 20, 2021.  3. Centers for Disease Control and Prevention. Division of Nutrition, Physical Activity, and Obesity at a glance. Available at: https://www.cdc.gov/chronicdisease/resources/publications/aag/dnpao.htm. Accessed October 20, 2021. 4. Laframboise MA, Degraauw C. The effects of aerobic physical activity on adiposity in school-aged children and youth: a systematic review of randomized controlled trials. J Can Chiropractic Assoc. 2011;55(4):256–268. 5. Center for Disease Control and Prevention. High School YRBS 2019. Available at: https://nccd.cdc.gov/youthonline/App/QuestionsOrLocations.aspx?CategoryId=C06. Accessed October 20, 2021. 6. Lounassalo I, Salin K, Kankaanpaa A, et al. Distinct trajectories of physical activity and related factors during the life course in the general population: a systematic review. BMC Public Health. 2019;19:1.   7. U.S. Department of Health and Human Services. Physical activity guidelines for Americans. Available at: https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf. Accessed October 20, 2021. 8. Castelli DM, Glowacki E, Barcelona JM, Calvert HG, Hwang J. Active education: growing evidence on physical activity and academic performance. Available at: https://activelivingresearch.org/sites/activelivingresearch.org/files/ALR_Brief_ActiveEducation_Jan2015.pdf. Accessed October 20, 2021. 9. Kari JT, Pehkonen J, Hutri-Kähönen N, Raitakari OT, Tammelin TH. Longitudinal associations between physical activity and educational outcomes. Med Sci Sports Exerc. 2017;49(11):2158–2166. 10. Kohl HW, Cook HD. Physical activity, fitness, and physical education: effects on academic performance. Available at: https://www.ncbi.nlm.nih.gov/books/NBK201501/. Accessed October 20, 2021. 11. Society of Health and Physical Educators. The essential components of physical education. Available at: https://www.shapeamerica.org/uploads/pdfs/TheEssentialComponentsOfPhysicalEducation.pdf. Accessed October 20, 2021. 12. Society of Health and Physical Educators (2016). 2016 shape of the nation: status of physical education in the U.S. Available at: https://www.shapeamerica.org//advocacy/son/2016/upload/Shape-of-the-Nation-2016_web.pdf. Accessed October 20, 2021. 13. Springboard to Active Schools. Keep recess in schools. Available at: https://www.cdc.gov/healthyschools/physicalactivity/pdf/Recess_Data_Brief_CDC_Logo_FINAL_191106.pdf. Accessed October 20, 2021. 14. Ohinmaa A, Langille JL, Jamieson S, Whitby C, Veugelers PJ. Costs of implementing and maintaining comprehensive school health: the case of the Annapolis Valley Health Promoting Schools program. Can J Public Health. 2011;102(6):451–454. 15. Barrett JL, Gortmaker SL, Long MW, et al. Cost effectiveness of an elementary school active physical education policy. Am J Prev Med. 2015;49(1):148–159. 16. Physical Activity Council. (2017). 2017 participation report. Available at: http://s3.amazonaws.com/ustaassets/assets/822/15/papc_study.pdf. Accessed October 20, 2021. 17. Synder TD, de Brey C, Dillow SA. Digest of education statistics. Available at: https://files.eric.ed.gov/fulltext/ED580954.pdf. Accessed October 20, 2021. 18. Centers for Disease Control and Prevention. School Health Policies and Practices Study, 2014. Available at: https://www.cdc.gov/healthyyouth/data/shpps/pdf/shpps-results_2016.pdf. Accessed October 20, 2021. 19. Society of Health and Physical Educators. A-Z of social justice physical education. Available at: https://www.shapeamerica.org/uploads/pdfs/2020/publications/joperd/The-A%E2%80%93Z-of-Social%20Justice-Physical-Education-P1.pdf. Accessed October 20, 2021.  20. Community Preventive Services Task Force. Annual report to Congress: 2013. Available at: https://www.thecommunityguide.org/content/tffrs-physical-activity-interventions-increase-active-travel-school. Accessed October 20, 2021. 21. Lonsdale C, Rosenkranz R, Peralta L, et al. A systematic review and meta-analysis of interventions designed to increase moderate-to-vigorous physical activity in school physical activity lessons. Prev Med. 2013;56:152–161. 22. Zhou Y, Wang L. (2019). Correlates of physical activity of students in secondary school physical education: a systematic review of literature. BioMed Res Int. 2019;2019:4563484.   23. U.S. Department of Health and Human Services. Healthy People 2030 physical activity objectives. Available at: https://health.gov/healthypeople/objectives-and-data/browse-objectives/physical-activity. Accessed October 20, 2021. 24. Hollis JL, Sutherland R, Williams AJ, et al. A systematic review and meta-analysis of moderate-to-vigorous physical activity levels in secondary school physical education lessons. Int J Behav Nutr Phys Act. 2017;14(1):52.   25. Fairclough SJ, Stratton G. A review of physical activity levels during elementary school physical education. J Teach Phys Educ. 2006;25(2):240–258.   26. Powell E, Woodfield LA, Nevill AM, Powell AJ, Myers TD. ‘We have to wait in a queue for our turn quite a bit’: examining children’s physical activity during primary physical education lessons. Euro Phys Educ Rev. 2019;25(4):929–948. 27. Society of Health and Physical Educators. National PE standards. Available at: https://www.shapeamerica.org/standards/pe/. Accessed October 20, 2021.  28. United Nations Educational, Scientific and Cultural Organization. Guidelines for policy makers: quality physical education. Available at: https://en.unesco.org/inclusivepolicylab/sites/default/files/learning/document/2017/1/231101E.pdf. Accessed October 20, 2021. 29. Haughton J, Ayala G, Burke K, Elder J, Montanez J, Arrendondo E. Community health workers promoting physical activity. J Ambul Care Manage. 2015;38(4):309–320. 30. Hovell MF, Mulvihill MM, Buono MJ, et al. Culturally tailored aerobic exercise intervention for low-income Latinas. Am J Health Promotion. 2008;22(3):155–163. 31. Falbe J, Cadiz AA, Tantoco NK, Thompson HR, Madsen KA. Active and healthy families: a randomized controlled trial of a culturally tailored obesity intervention for Latino children. Acad Pediatr. 2015;15(4):386–395.   32. Joo JY, Liu MF. Culturally tailored interventions for ethnic minorities: A scoping review. Nurs Open. 2021;8(5):2078–2090. 33. APENS. Adapted Physical Education National Standards. Available at: https://apens.org/national_standard.html. Accessed October 20, 2021. 34. Centers for Disease Control and Prevention. The association between school based physical activity, including physical education, and academic performance. Available at: https://www.cdc.gov/healthyyouth/health_and_academics/pdf/pa-pe_paper.pdf. Accessed October 20, 2021.  35. World Health Organization. School policy framework: implementation of the WHO global strategy on diet, physical activity and health. Available at: https://www.who.int/dietphysicalactivity/SPF-en-2008.pdf. Accessed October 20, 2021.  36. Mayorga-Vega D, Saldias MP, Viciana J. Comparison of moderate-to-vigorous physical activity levels between physical education, school recess and after-school time in secondary school students: an accelerometer-based study. Kinesiology. 2017;49(2):242–251.   37. U.S. Department of Health and Human Services. Healthy People 2020. Physical activity objectives. Available at: https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity/objectives. Accessed October 20, 2021.  38. Community Guide. Physical activity: interventions to increase active travel to school. Available at: https://www.thecommunityguide.org/content/tffrs-physical-activity-interventions-increase-active-travel-school. Accessed October 20, 2021.  39. Centers for Disease Control and Prevention and Society of Health and Physical Educators. Strategies for recess in schools. Available at: https://www.shapeamerica.org/uploads/pdfs/recess/SchoolRecessStrategies.pdf. Accessed October 20, 2021.  40. Centers for Disease Control and Prevention. Strategies for classroom physical activity in schools. Available at: https://www.cdc.gov/healthyschools/physicalactivity/pdf/classroompastrategies_508.pdf. Accessed October 20, 2021. 41. Zavacky F, Michael SL. Keeping recess in schools. J Phys Educ Recreation Dance. 2017;88(5):46–53.   42. Bedard C, St. John L, Bremer E, Graham JD, Cairney J. A systematic review and meta-analysis on the effects of physically active classrooms on educational and enjoyment outcomes in school age children. PLoS One. 2019;14(6):1–19.

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Chagrin Falls Physical Education Teacher and Coach Pamela Malone retiring this week after 35 years of service

• Updated: Sep. 09, 2024, 9:21 a.m.
• | Published: Sep. 09, 2024, 8:59 a.m.

Chagrin Falls Health and Physical Education Teacher Pamela Malone is retiring after 35 years of service to the district. In 2022, Malone was named the United Soccer Coaches Association's National High School Coach of the Year. Chagrin Falls Schools

• Matt Leavitt, special to cleveland.com

CHAGRIN FALLS, Ohio -- After being named a National High School Soccer Coach of the Year (2022), winning two state soccer championships for the Tigers (1996 and 2021), and coaching numerous Tigers that have become professional athletes, Chagrin Falls Health and Physical Education Teacher Pamela Malone is retiring this week after 35 years of service to the district.

Malone was hired as a physical teacher at Chagrin Falls in 1989, after working for the Cleveland Clinic in their Wellness Program, as an on-air personality for WEWS Channel 5, and as a substitute teacher in the Orange School District. The physical education teacher recalls the hiring process, “It turns out that the (Chagrin Falls) principal, Dr. James Trusso was my principal when I was in high school at Mentor High School -- he remembered me and said ‘it’s yours if you want it’ -- the hiring process is a lot different now,” Malone said.

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Physical Education and Sports: A Backbone of the Entire Community in the Twenty-First Century

Jean de dieu habyarimana.

1 Department of Physical Education and Sports Training, School of Physical Education, Minglun Campus, Henan University, Kaifeng 475001, China; rf.oohay@ueidhdj

Etienne Tugirumukiza

2 Department of Physical Education and Sports Coaching, School of Physical Education and Sports Coaching, Shanghai University of Sport, Shanghai 200433, China; moc.liamg@21arigutenneite

Associated Data

To prevent the assumptions of availability of required data, the authors needed to ensure the availability of required data before further stages of the study.

The current state of physical inactivity of people can be traced back to the people who have been denied their fundamental human right to physical education and participation in school sports (PES). Growing up without the fundamental human right to free movement and participation in sports activities enabled students to stay physically inactive. The purpose of this study was to explore what is currently known about the role of PES in all areas of human development and SDGs and to raise awareness about PES, which has been shown to be on the decline. To increase the study’s overall efficacy, an external desk research approach was employed to gather relevant information published online: reports, policies, charters, recommendations, and other relevant articles from various electronic databases and websites of international organizations responsible for PES, culture, and health. PES benefits are discussed in all domains of human development, including physical and mental health, cognitive, psychosocial, and moral benefits. Contrary to its importance to human growth as a whole, PES has been sidelined since the end of the twentieth century. An awareness of the subject of PES has thus been raised as a backbone of the entire community in the twenty-first century, so as to translate the promises and policies of PES into realities and practices.

1. Introduction

One of the most significant current discussions in physical exercises and public health is that a decline in PES leads to a corresponding decline in physical activity (PA), which contributes to an increase in hypokinetic diseases among school-aged children and adolescents. PES (a planned, sequential K–12 standards-based program with written curricula and appropriate instruction designed to develop the motor skills, knowledge, and behaviors of active living, physical fitness, sportsmanship, self-efficacy, and emotional intelligence), according to SHAPE America [ 1 ], has the potential to make distinctive contributions to the development of children’s fundamental movement skills and physical competences, as well as support the development of social skills and behaviors, self-esteem, and preschool attitudes, and in certain circumstances, academic and cognitive development, according to Bailey [ 2 ].

The overall goal of PES is to make its pedagogical approach of educating the body to be permanent by teaching children about movement and developing the necessary skills to become proficient in many kinds of PA, as stated by Guedes [ 3 ], as well as to develop the patterns and interest in PA, which are essential for healthy development and lay the foundations for adult healthy lifestyle, as reported by ICSSPE [ 4 ]. According to SHAPE America [ 1 ], the purpose of PES is to develop the motor skills, knowledge, and behaviors of active living, physical fitness, sportsmanship, self-efficacy, and emotional intelligence. In other words, UNESCO [ 5 ] elucidated that PES should be effectively implemented in order to provide a platform for broad social inclusion and develop the skills and knowledge necessary to define new forms of global citizenship. In this regard, UNESCO [ 6 ] proclaimed that the practice and full participation in PES is a fundamental human right for all. In this light, Wright et al. [ 7 ] substantiated that the school setting remains one of the conducive environments for promoting a physically active lifestyle among children and adolescents.

However, as stated by UNESCO [ 5 ], Weedon et al. [ 8 ], and Louis [ 9 ], PES is on the decline. PES declination has been strongly evidenced by UNESCO [ 10 ] in its survey conducted in all regions across the globe, revealing that (a) PES is being replaced by core subjects such as mathematics, the science subjects, language, arts, etc.; (b) PES-allocated curriculum time is being diverted to such core subjects; (c) PES teachers are being assigned other duties, such as logistics; and (d) PES is being replaced by cleaning or sending students home. On a related note, UNESCO [ 10 ] has stated that PES has lower esteem and status compared to other subjects. This was especially noticeable in North America, Africa, and the Middle East, with 77%, 69%, and 65%, respectively. Subsequently, the average time allocated to PES in primary and secondary schools remains low, i.e., 97 and 99 min, as against an ideal of 120 and 180 min in primary and secondary schools, respectively. Apart from insufficient curriculum time allocation, cancellation of PES lessons has also been reported to the extent of 100% in North America, 65% in both Africa and the Middle East, and 52% in Latin America/Caribbean, according to UNESCO [ 10 ].

On account of this PES downturn, the prevalence of global physical inactivity among children and youth has been observed to be particularly high. For instance, the findings of a research study conducted by Guthold et al. [ 11 ] reported that 81% of adolescents were not physically active, of which 77.6% and 84.7% were boys and girls, respectively. Another example of what Guthold et al. [ 11 ] meant is that observed by Kimm et al. [ 12 ], who reported a 100% and 64% decline in habitual leisure-time PA for African-American girls and White girls by the age of 16 or 17 years old, respectively. From this standpoint, it was noted that such a decline in PA increases with age, particularly in high-income countries, according to Hallal et al. [ 13 ] and Corder et al. [ 14 ]. More recently, Remmers et al. [ 15 ], Telama and Yang [ 16 ], and Caspersen et al. [ 17 ] published research studies that show that PA decline occurs between the ages of 12 and 13 years onwards. At this point, it is worth noting that Aubert et al. [ 18 ] observed that more than 70% of youngsters in various countries do not meet the PA level needed for a healthy life. Increasingly important is the fact that only 20% of the world’s adolescents are physically active, according to WHO [ 19 ].

In a similar vein, it has been pointed out that one in four, equivalent to 23% of adults, and three in four, equivalent to 81%, of adolescents aged 11–17 years do not meet the global WHO recommendations on PA for health, according to UN-Habitat [ 20 ].

In view of this emerging physical inactivity, sedentary health-based diseases and disorders, as well as the global health crisis, remain unresolved issues. According to Toschke et al. [ 21 ], chronic diseases have been particularly prevalent among children and adolescents, due to a lack of effective PA. To further clarify this, according to WHO [ 22 ] and Lin et al. [ 23 ], over 340 million children and adolescents aged 5–19 were classified as overweight or obese in 2016, while 476.0 million children and adolescents were diagnosed with diabetes mellitus in 2017.

Increasingly, negative consequences in various domains such as physical (worsened bone density, strength, and flexibility), psychological (increase in the occurrence of major depression, poor concentration and self-esteem, negative bullying), and academic (decrease in standardized test grade) have also been reported by Rasberry et al. [ 24 ]. Above all, physical inactivity was ranked third among the six risk factors, accounting for 19% of global fatalities and 7% of global DALYs. Moreover, according to WHO [ 25 ], physical inactivity is responsible for 21–25%, 27%, and 30% of breast and colon cancer burden, diabetes, and ischemic heart disease burden.

In another example, WHO [ 26 ] reported that mental health conditions currently account for 16% of the global burden of diseases and injury in children aged 10–19 years old. In this light, depression has been identified as one of the leading causes of illness and disability among adolescents. Similarly, suicide is reported as the third leading cause of death in children aged 15–19 years old.

Physical inactivity is increasingly recognized as a serious, worldwide public health concern, especially among young people (school-aged children and adolescents). This is happening at a time when PES, which has been shown to be a single subject with the potential to provide the students with various benefits, including health-related ones, UNESCO [ 5 ] (p. 6) is on the decline. In fact, it is evident that the entire community is suffering from a physical inactivity epidemic, especially among young people. As such, research to date has tended to focus on PA rather than PES.

This current paper therefore seeks to remedy these problems by analyzing the significance of PES in various domains identified as cognitive, physical, affective, healthy, social, moral, cultural domains, and SDGs as well as raising an awareness of PES in order to encourage governments, organizations responsible for PES, and schools to translate promises into practice.

2. Brief Background of PES

The starting point of PES can be traced back to the early societies, whereby their education philosophy was, according to Van Dalen and Bennett [ 27 ], education for survival. In this regard, the purpose of education was to ensure the survival of society. Thus, the curriculum was made up of courses such as hunting, throwing, running, jumping, etc., in line with strengthening the people to find food and protect their families against harmful animals and other disasters.

In a similar vein, the philosophical foundation of ancient Greeks on education was the notion of dualism, which, in the Greek curriculum, was featured under two components, namely gymnastics and academics, according to Laker [ 28 ]. In essence, education aimed to ensure the aesthetic and physical development of the body by means of sport; specifically, Sparta promoted PES by targeting military fitness, as opposed to the more holistic education for Athens.

During the Dark Ages, the aims of developing the body and mind equally that came from the Greek civilization, which considered the body as a partner or guardian of the mind and soul, became devalued. Later on, during the Renaissance (rebirth, discovery age), the development of a complete person as a priority was recovered by the Greeks, since such fully educated people were in need to take their place in a polite and cultured society. Hence, PES as a component of holistic education was in service of the needs of the society, according to Laker [ 28 ]. Until around 1820, much of focus of schools was on PES expressed in gymnastics, hygiene training, and care and development of the human body. By the year 1950, major courses in PES had been introduced in over 400 institutes to promote PES.

Even though this was considered an outstanding progress, it did not lead to the success of PES as a legitimate subject in all schools worldwide. The evidence suggests that, later in the 20th century (1970s–1980s), PES suffered a strong decline that is associated with the increased availability of other subjects, whereby the attention, time, and values assigned to PES were shifted to academics, according to Excite Education [ 29 ].

Consequently, it was noted that both pedagogy professionals and practitioners failed to assume their responsibilities of clarifying the nature of the field at the school level and advocating for its restoration in order to address the PES crisis, as claimed by Guedes [ 3 ]. Realizing this crisis, UNESCO initiated and enforced the international charter of PES across the world on 21 November 1978.

With the PES decline, the International Council for Sport Science and Physical Education (ICSSPE) was established to tackle the problem at hand. It is in this context that the first international summit was organized on 3–5 November 1999 in Berlin by ICSSPE with support from the International Olympic Committee (IOC), United Nations Educational Scientific and Cultural Organisation (UNESCO), and WHO, bringing together policymakers, physical education practitioners from around the world, researchers, and administrators to share all necessary information concerning PES.

Reporting his observations, Hardman [ 30 ] documented his findings from the international summit which reaffirmed the perilous position of PES to the extent that the UNESCO’s 1978 international charter of PES was found to be unimplemented. What is more, it was noted that PES was pushed into a defensive position under which it faced a reduction of curriculum time allocation, deficient resources (financial, material, and human), and marginalization associated with low value, status, and esteem by authorities. Until now, there has been a need to turn promises into realities and policies into actions if threats are to be vanquished and a convenient future for PES is to be maintained.

3. Material and Methods

This review was conducted by adopting the external desk research method from Mangal and Shubhra [ 31 ] used to enhance the overall effectiveness of the research. For the purpose of this study, a comprehensive search was carried out to retrieve related reports, policies, charters, guidelines, international position statements, and support statements, as well as other relevant documents and articles. For the sake of documenting the analysis method, as well as inclusion criteria, a search protocol was designed in advance. In so doing, a search strategy for the identification of works in the relevant literature containing key terms in their title and abstract was developed. This search strategy was tailored to Google Scholar, ScienceDirect, PubMed, and Eric. The search terms used with Boolean Operators were “physical education and school sports” AND “cognitive OR physical OR affective OR healthy OR social OR moral OR culture” OR “Sustainable development goals”.

The search focus was mainly on the existing English literature related to the role of PES in the field of social sciences and health sciences. Thus, it was narrowed to subject areas identified as PA, sports, recess, recreation, and dance. The researchers included study publications, reports, and data and information from census or other scientific data-collection procedures to ensure validity and dependability. Thus, in light of preventing personal bias, information and data collected from personal diaries, newspapers, and magazines were excluded from this study. Similarly, the researchers ensured that the relevant data were available before undertaking further stages of this study in order to avoid making assumptions about the availability of the required data.

4. Benefits of Physical Education and School Sports

The European parliament 2007 resolution [ 32 ] declared the following: “PES has the propensity to make significant and distinctive contributions to children, schools and wider society: respect for the body, integrated development of mind and body, understanding of PA in health promotion, psycho-social development (self-esteem and self-confidence), social and cognitive development and academic achievement, socialisation and social skills (tolerance and respect for others, co-operation and cohesion, leadership, team spirit, antidote to antisocial behavior) and aesthetic, spiritual, emotional and moral (fair play, character-building) development, a panacea for resolution of the obesity epidemic, inactivity crisis and sedentary lifestyle, enhancement of quality of life etc.”.

PES, according to SHAPE America [ 1 ] creates a framework of life skills that shapes the whole person, encouraging smart choices and cultivating a healthy lifestyle, while both PA and effective PES are proven essential elements in the formative growth of children and adolescents, as well as an evidence-based approach to improving academics and benefiting students’ physical, cognitive, and mental health. The section hereunder therefore explored the role of PES under cognitive, physical, affective, healthy, social, moral, cultural domains and SDGs.

4.1. Cognitive, Academic Performance and Brain Health

A healthier body, academic performance, cognitive development, and lifelong brain health have all been linked to the time students spent participating in PA either as a one-time event or habitual. As a matter of fact, Plato, Aristotle, and Rousseau, the classical scholars of education in the 18th century, contended that the development of the body has to balance that of the mind [ 33 ].

To bring to light the issue of improved academic performance and cognitive development through PES, several studies have been carried out to establish the contribution of PES in improving students’ cognitive development, brain health, and academic achievements.

As a matter of concern, improvement in measures of cognitive skills and attitudes are positively benefited from improved PA engagement level in PES. Hence, participating in a prolonged PA at school helps the students to increase their cognitive preparation processes because of a more effective working memory network, as reported by Boykin and Allen [ 34 ], Oja and Jürimäe [ 35 ], Reynolds and Nicolson [ 36 ], and Kamijo et al. [ 37 ].

In the same way, cognitive benefits such as executive function are accrued from PA participation no matter how long it lasts or how intense or frequent it is. Rather, Budde et al. [ 38 ] found that even a single occurrence of high-quality PA can improve children’s or teenagers’ executive function scores in an executive function test.

More importantly, Kramer et al. [ 39 ] bolstered that participating in PA improves not only cognitive development and academic performance of the students involved but also contributes significantly to maintaining healthier cognition in adulthood and even at old age. Thus, there is evidence that early childhood participation in PA helps in combating cognitive aging.

Equally important is the fact that improved academic performance has been closely associated with PA participation in conditions where students need to spend a certain period of time with a given intensity or in some cases frequently/repetitively.

In this case, Donnelly and Lambourne [ 40 ] established that regular participation in PES increases the students’ academic performance. This is evident in the case of Bartholomew and Jowers [ 41 ], who noted that better attention in the classroom, as well as on-task behaviors and concentration, is influenced by PES, which, in turn, results in improved academic performance.

The next similarity is an assertion made by Hillman et al. [ 42 ], emphasizing the function of PES in improving attention allocation and working memory to a single cognitive activity completed, regardless of the intensity and time constraints. A supportive view of Hillman et al.’s assertion was articulated by McNaughten and Gabbard [ 43 ], who stressed that even a short bout of PA equivalent to 30 min positively affects cognitive functioning in school-aged children.

Other researchers have also revealed that the positive effect of PES is more likely to be achieved provided that PA is delivered over a long period of time. In this regard, Gabbard and Barton [ 44 ] emphasized that a significant improvement in academic achievement such as mathematics performance is achieved through long participation in PA for at least 50 min. On a related note, the CDC [ 32 ] insisted that PES serves a positive impact on academic achievement if the overall PES time is increased.

In a similar light, it has been indicated that students’ executive functions such as attention and inhibition, healthy attentional process, perceptual skills, intellectual quotient, verbal tests, mathematics tests, memory, readiness, cognition, and emotional regulation and balance are increased when PES subject is given a high priority by allocating more time to engage students in moderate-to-vigorous PA, which results in overall academic performance, according to Sallis and Owen [ 45 ]; Verdine et al. [ 46 ]; Etnier and Sibley [ 47 ]; and Stevens [ 48 ].

As far as brain health is concerned in relation to PES, different researchers have conducted a variety of studies and come up with different views about the benefits of PA to brain health. PA affects the physiology of the students’ brain by increasing cerebral capillary growth, blood flow, oxygenation, production of neurotrophins, growth of nerve cells in the hippocampus, neurotransmitter levels, development of nerve connections, density of neural network, and brain tissue volume, according to Trudeau and Shephard [ 49 ], Hillman et al. [ 50 ]; and Rosenbaum et al. [ 51 ]. Greater attention, information processing, storage, and retrieval; improved coping and positive effect; and reduced cravings and pain sensations have all been linked to physiological changes in the brain.

Hills [ 33 ] argued that active engagement in PES improves academic performance by increasing blood flow to the brain, increasing mental alertness, enhancing mood, and increasing self-esteem. Consistent with the findings of Hills is the findings of Shephard [ 52 ], which stated that changes in cognitive functioning (increased blood flow into the brain, increased level of arousal, and stimulated brain development) are a reflection of any improvement in academic performance after engaging in PES.

Contrary to the above are the opposing views obtained from other studies undertaken to ascertain the cognitive, academic performance, and brain health benefits achieved through participation in PES; they revealed no relationship between these variables, even though the former determined the significant impact. Such contradictions are dependent on the dose prescribed to PES so as to offer the benefits ascribed to it.

Fisher et al. [ 53 ] argued that active participation in PES has no correlation with academic performance. Moreover, Ahamed et al. [ 54 ] found no significant difference between the treatment and control group in a standardized cognitive abilities test after 16 months of a classroom-based PA intervention under a cluster randomized trial.

In the same way, Tinning and Kirk [ 55 ] found no difference in academic subjects between the students who were allocated 90 min/day participating in PA and those who had not been engaged in such a program. Parallel to these opposing views, Melnick et al. [ 56 ] found no or a trivial correlation between active participation in PES and academic achievement.

Another point to note is the null findings that were revealed between the contribution of PA and the cognitive or healthier brain. According to the null findings, PES is established neither to harm nor to benefit the students with cognitive development, academic performance, and brain health while engaging in PES. In this specific instance, on the completion of his study, Bailey [ 57 ] noted that increased PES time does not negatively affect cognition. Moreover, Trudeau et al. [ 58 ] and Trudeau and Shephard [ 59 ] confirmed that PES has no ill effect on academic learning.

The aforementioned existing literature that we reviewed presented contradictory views about the contributing benefits of PA to cognitive development, academic performance, and brain health of the concerned students, whereby some researchers revealed a significant association between these variables, while others found no relationship, regardless of those that claimed null findings.

Due to this inconsistency, in contrast to several research studies that undoubtedly confirmed various benefits of PES, it is clear that robust longitudinal cause-and-effect research is needed to explore the role of participation in a particular PA on cognitive development, academic performance, and brain health, since disagreements remain rampant on whether the relationship between PA and academic achievement is causal. It is also clear that further understanding is needed to ascertain the level of intensity and duration that children need to reach so as to fully gain the cognitive benefits available by participating in PA. However, much work still needs to be performed in order to examine the appropriate type of physical exercises to be undertaken concerning culture, gender, and age level of students such as children and adolescents that can lead to cognitive benefits, since educational demands change as children and adolescents change. Therefore, PES should be one of the compulsory subjects that is allocated appropriate time on schools’ timetable to expose students to a planned exercises providing the students with the opportunity to gain such benefits regardless of dose or intensity.

4.2. Physical Domain

PA has been established as one of the leading factors influencing physical health by curbing the causes of diseases, reducing the risk of chronic diseases, enhancing efficient functioning of the body, and providing remedial benefits, as well as health-related fitness within childhood and adolescence; and it continues throughout adulthood and old age toward a satisfactory future life, according to Sallis and Owen [ 45 ]; Bailey [ 57 ]; and Fernandes and Sturm [ 60 ].

In essence, Bailey [ 57 ] emphasized that PES significantly benefits the participants with general health through efficient functioning of the body; the remedial benefits include the correction of poor posture and the developmental benefits such as assisting the natural pattern of growth of the child.

Consistent with the view of Bailey are the emerging points documented by several researchers who argued that participating in quality PES improves the physical status of the participants in terms of body mass index, resulting in a normal weight within the school period and in the future. Fernandes and Sturm [ 60 ] pointed out that effective participation in PES diminishes the potential for future mass increase among children. In their own words, Madsen et al. stated, “more physical education is associated with lower Body Mass Index scores” [ 61 ]. On a related note, Cawley et al. [ 62 ] made it clear that PES lowers both body mass index and the probability of obesity among grade-five male students. This was also exemplified in the work undertaken by Freedman et al. [ 63 ], who substantiated that engaging in quality PES from early childhood prevents obesity, which, indeed, starts at childhood and persists all through life, leading to the risk of being affected by hypokinetic diseases such as coronary heart diseases and diabetes.

Another supporter of PES and health-related fitness, Sdrolias [ 64 ], in his study undertaken in secondary schools, contended that quality PES results in a significant improvement in health-related fitness and psychological well-being in high-school students. Similarly, it has been noted that PES reduces the odds of being an overweight adult by 5% each day per week, while normal-weight children are 25% more likely to be normal-weight adults if they participate in PES at least five days per week, according to Mensschik et al. [ 65 ].

The most obvious and important benefit of active PA engagement is the significant improvement in health-related fitness components (aerobic fitness, muscle strength and endurance, flexibility, and body shape) in both school-aged children and adolescents, due to active PA participation. To bring this assertion to light, Chen et al. [ 66 ] examined the relationship between students’ physical fitness components and PA and noted that engaging in PES and recess, as well as sports/dance, significantly influences the overall health-related physical fitness. This finding is in line with the findings of the study conducted by Sallis et al. [ 67 ], who ascertained a significant association between the level of PA and health-related physical fitness among school-aged children and adolescents.

Unfortunately, PES, a single curriculum subject under which school-aged children and adolescents are supposed to gain opportunities to engage in quality Pas, UNESCO [ 5 ] (p. 6), has been mostly sidelined to the extent that physical inactivity has been declared one of the leading causes of death, disability, and insufficient quality of life, particularly in the Western world, according to USDHHS [ 68 ]. On the other hand, UNESCO [ 10 ] reported that PES is globally cancelled at 44%, despite the fact that it has been confirmed globally to be a compulsory subject, at 97%. This is a fact that indicates the inconsistency in translating policies into implementations. It is therefore clear that PES needs to be fully restored and maintained in schools by exposing the students to quality PES instruction within a recommended time depending on school level (elementary/secondary) or gender to serve its physical benefits to the students.

4.3. Affective Domain

Currently, affection is understood as a psychological and emotional well-being with associated components, namely mastery motivation, sense of autonomy, moral character, confidence, emotion, preference, choice, feeling, beliefs, attitudes, and appreciations, according to NRCIM [ 69 ].

At the same time, many affective benefits, such as happiness, enjoyment, and self-confidence, have been associated with active participation in PA. WHO [ 70 ], in its study about sports and children, validated that participation in PES improves self-esteem, self-perception, and psychological well-being of the participants.

As Gilman [ 71 ] has noted, the students who participate in PA experience more happiness compared to those who do not participate. A view that supported Gilman’s assertion is articulated by Bailey et al. [ 72 ], who pointed out that the 1909 syllabus clearly points out the affective outcomes of physical exercises as producing a cheerful and a joyful mood, as well as the expression of emotion. Some other interested researchers went further to determine the role of such happiness/enjoyment in future PA participation. Williams and Gill [ 73 ] and Sonstroem [ 74 ] reported that such happiness experienced within PA reinforces self-esteem, which, in turn, enhances further participation. Kimiecik and Harris [ 75 ] made it clear that such happiness also improves intrinsic motivation, which lowers anxiety, thus increasing participation.

Along the same lines, other studies have revealed some psychological benefits of PES participation. Mutrie and Parfitt [ 76 ] indicated that a positive correlation exists between PA participation and psychological benefits such as the reduction of stress, anxiety, and depression, as well as emotional growth and expression. Active engagement in PES reduces anxiety and depression and increases positive mood, self-esteem, and restful sleep, according to Dunn et al. [ 77 ] and Landers [ 78 ].

Although these aforementioned findings may be valid, a view that contradicts the former is that of Steptoe et al. [ 79 ], who rejected the opinion of a positive association between PA and affective domain of human development after he conducted a study across 21 countries which involved 16,000 undergraduate students. He established a negative correlation between PA, exercises, and depression symptoms.

After all, not much is known about the mechanisms by which such dimensions of affective development occur, according to Dishman [ 80 ]. Increasingly, Thirlaway and Benton [ 81 ] raised an existing confusion that it is unknown whether some forms of PA are more or less beneficial to the improvement of the affective domain than others. Whereas other arguments have rejected the idea that all groups experience psychological benefits from being active.

To this end, it is clear that PES needs to be resumed and should serve the students with all affective benefits discussed in the aforementioned literature. Although much research still needs to be performed in order to ascertain the genuine mechanism and appropriate form of PA that is more likely to serve affective benefits to the students, qualified, trained, and competent teachers are needed to instruct the students through some instructional curriculum models such as sports education, teaching personal and social responsibility, cooperative learning, etc., that are evidenced to promote the affective domain.

4.4. Healthy Domain

Earlier in the middle of the 20th century, PES targeting health-related fitness came into existence. This is undoubtedly due to the evidence that indicates the function of PES in improving the quality of life through its benefits to the muscles, bones, joints, heart, and mental health, just to mention a few, among school-aged children and adolescents who continue to adulthood and old age. In this regard, several studies have been conducted to find out the role of PES in maintaining health and preventing the causes of some diseases that emerge as a result of a sedentary health style.

According to the Institute of Medicine (IOM) [ 82 ], PA has several benefits in regard to various aspects of health, such as improved aerobic capacity, muscle and bone strength, flexibility, insulin sensitivity, and lipid profiles, resulting in the reduction of the risk of heart diseases, mental illness, and other chronic diseases, such as diabetes mellitus, osteoporosis, obesity, etc. These findings of IOM are in line with the findings of Bloomfield et al. [ 83 ], who carried out a research study on the role of PA on the life of the participants’ skeleton, bones, joints, and muscles. The findings of their study revealed that there is an increase in mineral accrual; an increase in bone strength which, in turn, reduces the risk of osteoporosis-related fracture; and, ultimately, an improvement in muscle strength, flexibility, coordination, and balance, as these are found to be significantly influenced by PA participation. A supportive view was observed in the study conducted by Masurier and Corbin [ 84 ], who reported that active participation in regular PA significantly reduced the risk of major chronic diseases such as heart diseases, high blood pressure, stroke, some forms of cancer, diabetes, and osteoporosis. On a related note, WHO [ 85 ] substantiated that PA enhances physical fitness in the areas of cardiorespiratory and muscular fitness; improves cardiometabolic health, particularly in blood pressure, dyslipidemia, glucose, and insulin resistance; improves bone health, mental health, and cognitive achievement; and reduces visceral adiposity.

More importantly, the literature shows that PA is beneficial to people of all ages, including children, adolescents, adults, and the elderly, provided people effectively participate in it. Hallal et al. [ 86 ] noted that the future morbidity (risk of fracture) is influenced by early PA, which is of great importance in the treatment, as well as the reduction in the rate and the severity of, some hypokinetic diseases in children and adolescents. Focusing particularly on children, the CDC [ 87 ] elucidated that engaging in PES and recess at school contributes much to improving cardiorespiratory and muscle fitness, as well as the promotion of a healthier body weight and body composition in children. Supporting this advancement of the CDC, the USDHHS [ 68 ], the CDC [ 87 ], and Bauman [ 88 ] asserted that a lower rate of chronic diseases such as coronary heart diseases, cardiovascular diseases, diabetes mellitus, hypertension, osteoporosis, and some types of cancer; and the reduction of premature death are some of the benefits adults gain due to actively engaging in PA.

Nonetheless, a controversy has erupted over the most effective PA dose, including the type, intensity, and frequency required to provide students with such health-related benefits. On the one hand, some scholars claimed that no matter how long, how intensely, or repetitively you engage in PA, benefits will be accrued. On the other hand, the researchers emphasized that there is need for a specific dose standard that must be met in PES so as to obtain the benefits accruable in PES. Of utmost importance is the fact that intense and frequent aerobic PA has been strongly evidenced to provide many health-related benefits.

Boreham et al. [ 89 ] and Imperatore et al. [ 90 ] ascertained that aerobic endurance corresponds with high-density lipoproteins, systolic and diastolic blood pressure, body mass index, measures of fatness and insulin sensitivity, and arterial stiffness. Associated with the views of Boreham et al. [ 89 ] and Imperatore et al. [ 90 ] are the findings of the experimental study undertaken by Davis et al. [ 91 ] which indicated a reduction in body fat among children and adolescents suffering from obesity or overweight when made to start aerobic exercises early in the program.

Taking into account the intensity and duration of aerobic PA, Baquet et al. [ 92 ] bolstered that regular moderate or vigorous intensified aerobic exercises undertaken within 30–45 min per session three days per week within three months resulted in increased cardiorespiratory endurance by 5–15% in youth. Similar to frequent PA, Corbin et al. [ 93 ] revealed that participating in PA improves immunological function and curbs the symptoms of arthritis, asthma, and fibromyalgia.

Masurier and Corbin [ 84 ] stressed that early PA in life acts similar to a vaccine for many diseases which attack the body later in life, and it also reduces the risk of diseases, thus improving the quality of life. Equally important are the health-related benefits from anaerobic physical activities, i.e., strength training or resistance exercises. In this case, Faigenbaum [ 94 ] established that anaerobic physical exercises positively enhance the quality of different aspects of the health of participants such as cardiovascular fitness, body composition, blood lipid profiles, and insulin sensitivity. Consistently, MacKelvie [ 95 ] insisted that strength training improves bone mineral density and bone geometry.

As far as PES and mental health are concerned, mental illness has been regarded as a global burden. This is because, by 2010, mental illness accounted for 15% of the global disease burden, according to Biddle and Mutrie [ 96 ] and Biddle and Asare [ 97 ]. Young people are particularly vulnerable to mental illnesses such as depression, anxiety, and the rest of the mental health disorders. Though mental illness may seem alarming, evidence has shown that PA can help to reduce and avoid mental illnesses such as anxiety and depression, as well as improve other elements of well-being, leading to long-term mental health, according to Ahn and Fedewa [ 98 ], and IOM [ 82 ]. Similarly, Ahn and Fedewa [ 98 ], Simms et al. [ 99 ], Biddle and Mutrie [ 96 ], and Dishman et al. [ 100 ] reported that active participation in PA lowers or reduces depression and its symptoms, anxiety and its sensitivity (a precursor to panic attacks and disorders), physiological distress, state of confusion, anger, and stress. It also improves mental health, dietary choices, and mood.

From the aforementioned literature we reviewed, PES has a substantial association with various aspects of health, including the body, skeleton, organs, and mental health.

In contrast, a sedentary health lifestyle is currently a major determinant of people’s health outcomes throughout their lives; an issue that could be linked to a lack of effective PES, which increases the risk of developing chronic diseases such as hypertension and coronary heart disease; mental health issues such as anxiety and depression; cancers such as colon and breast cancer; and even diabetes mellitus, osteoporosis, etc.

The crux of the matter is that, among the American adult population, 66% are overweight and 32% are obese. Approximately 19% of children and 17% of adolescents are overweight, and 37% of children and 34% of teenagers are either overweight or at risk of being overweight, according to Masurier and Corbin [ 84 ]. These facts indicate that several mandates that maintain PES as a compulsory and inclusive subject delivered to both boys and girls remain elusive. Therefore, there is need for a rationale to raise awareness about PES to be recognized as an important subject whereby trained PES teachers, materials and equipment, weekly time allocated to PES on the timetable, and an adequate budget are put in place to serve its purpose for school-aged children and adolescents.

4.5. Social Domain

PES is seen as a single bedrock subject that equips students with social interaction within this technological era, which is no longer providing the opportunity for people to meet and socialize, as it should naturally be. In some respects, students, to some extent, enjoy various opportunities of meeting and communicating, developing leadership skills, and ultimately learning social skills and behavior, while curbing, at the same time, the anti-social behaviors through PES.

In view of this perspective, Hellison et al. [ 101 ] indicated that participation in PES instils positive social behaviors in school-aged children and adolescents, such as cooperation, personal responsibility, and empathy. Afterwards, such participation in some circumstances helps in curbing current youth epidemics such as depression, crime, alcoholism, and drug abuse. In its recent report, SHAPE America [ 1 ] pointed out constructive competition, conflict resolution, decision-making, cooperation, and leadership assumption aspects as some of the benefits students gain through their interaction in PES.

In a similar vein, the Europe report asserted that only PES provides students with the opportunities of meeting and communicating with others and developing leadership qualities. More importantly, it instructs the participants about relevant social skills such as tolerance, respect for others, adjusting collectivism aspects including teamwork-spirit, cooperation, and cohesion, just to name a few, according to Svoboda [ 102 ]. Another emerging view which supports this assertion was articulated by Bailey et al. [ 72 ], who addressed the influence of PES on current global cleavage by arguing that PES has the potential to connect children of different social/economic classes and even those coming from different nations.

Of particular concern, the Qualifications and Curriculum Authority (QCA) [ 103 ] reported the constructive and corrective impact of PES, whereby it helps in improving students’ attendance, behavior, and attitudes within the school, as well as lowers the anti-social and criminal behaviors, according to Andrews and Andrews [ 104 ]. Indeed, the views of (QCA) and the Andrews corroborated with the assertion articulated by Sport England (SE) [ 105 ] that stated that participation of school-aged children and adolescents in PES assists them to gain social outcomes such as opportunities for active citizenship, increasing their attitude for learning as well as reducing youth crime and truancy.

In contrast to the social benefits ascertained by several researchers and scholars introduced herein, PES has been being devalued through different forms pushing it into a defensive position identified as (a) attributing low status to PES teachers; (b) assigning alternative duties to PES teachers such as logistics; (c) diverting PES time, which is already insufficient, to core subjects; and, in some schools, (d) replacing PES time with cleaning, etc., according to UNESCO [ 10 ]. As a consequence of this PES devaluation, students are still experiencing unpleasant social behaviors such as disrespect among themselves and some other related behaviors, such as truancy, absenteeism, alcohol and drug abuse, crime, and intolerance, just to name a few, as reported by Jean de Dieu and Andala [ 106 ].

Therefore, there is the need to call upon governments of nations to enforce PES in schools, as stated not only in international policies but also in their national PES policies such as to remedy the status of PES teachers through adequate continuous professional development (CPD) so as to update their pedagogical content knowledge (PCK) and current pedagogical models appropriate to serve social benefits such as teaching personal and social responsibility model, allow them to regularly teach PES following timetable, and make PES a compulsory subject with accountability for attendance and performance such as the other compulsory subjects so as to bridge the gap between agreements and actions.

4.6. Moral Domain

Moral behavior refers to activities conducted by following the rules which apply in a certain social context such as formal school/class rules, informal societal norms, and even the expectations related to behavior. Thus, moral values include honesty, fairness, fair play, justice, and responsibility, as reported by Wright and Taylor [ 107 ], Lumpkin and Stokowski [ 108 ], and Stoll and Beller [ 109 ]. According to this perspective, the existing evidence suggests that many moral benefits, such as experiencing moral socialization, moral values, ethical behavior, citizenship education, and social and moral characters, are accrued from participating in PES when students are given the opportunity to engage in an effectively planned PES.

A notable example of these moral benefits was found in studies undertaken by Bloom and Smith [ 110 ] and Sabock [ 111 ], who elucidated that PES provides the students with many opportunities to experience moral values such as cooperation, competition, role-playing, rules, regulations, and goal-based discipline. Moreover, PES assists in gaining self-discipline and order, manual dexterity, and even determination, according to Bloom and Smith [ 110 ], and Bailey [ 57 ].

In his own words, Sabock [ 111 ] (p. 271) argued that “the arena of sport can provide one of the greatest opportunities for a student to learn honesty, integrity, and ethical behaviour”. It is becoming increasingly important that PES has been proven to be a paramount subject, simultaneously instilling in the students social and moral characteristics such as cooperation with teammates; negotiation and creation of solutions against moral conflicts; development of self-control, fairness, and good work ethics; and displaying courage and learning of virtues such as teamwork, as reported by Shields and Bredemeier [ 112 ] and Weiss and Bredemeier [ 113 ]. The next likeness was the view articulated by Romance et al. [ 114 ], who argued that active participation in PES has been established as a source of positive moral socialization, and, to some extent, deliberate interventions in PES settings can improve moral conduct.

Another emerging feature of a moral aspect through PES is a view that effective PES has been indicated as a foundation for good citizenship. Engh [ 115 ] suggested that quality PES results in a good citizen education, which is, indeed, what PES teachers are supposed to teach in educational athletics as they teach other PES components. Supporting Engh, Raakman [ 116 ] substantiated that participation in PES could help develop engaged and balanced citizenship.

Despite the fact that PES positively influence the students’ moral development, the contrarians against this prevailing knowledge argued that PES participation may be a causal agent of negative moral development among participants, according to Bredemeier and Shields [ 117 ], Priest et al. [ 118 ], and Collin [ 119 ]. Another view that contradicts the view of a positive association between PES and moral education was found in the study conducted by Collin [ 119 ], who noted that unethical and aggressive behavior, which destroys the development and well-being of young athletes and the whole society, can be the result of a win-at-all-costs philosophy.

Despite these contradictions in moral benefits accrued from PES participation, it is important to note, however, that the quality PES delivered by professionally trained and qualified PES teachers adopting some of the current pedagogical models acknowledged to promote moral aspects of the students through their constructivism approach, including sports education, which focuses not only on playing roles but also duty roles, has been acknowledged to serve the needful under the moral domain. Thus, PES needs to be welcomed in schools to serve all moral benefits attributed to it.

4.7. Cultural Domain

UNESCO [ 120 ] defined culture as the set of distinctive spiritual, material, intellectual, and emotional features of society or a social group that encompasses not only art and literature but also lifestyle, ways of living together, value systems, traditions, and beliefs. In a similar vein, Zimmerman [ 121 ] made it clear that culture involves religion, food, language, marriage, music, dressing style, the dualism of what is right and wrong, rituals, ceremonies, etc.

In contrast to the other domains, finding existing works in the literature that addressed the contribution of PES to maintaining or improving the culture of a given society, turned out to be complex. However, some views have been pointed out by some relevant organizations and scholars, indicating that PES plays a significant role in encouraging school-aged children and adolescents to recognize and respect each other’s cultural characteristics, resulting in the prevention of some bad feelings such as extremism and racism, among others.

An example of this act was found in the International Charter of PES, UNESCO [ 6 ] which justified that the right and freedom of participating in PES should be granted without discrimination of any characteristics, including color, gender, language, religion, national or social origins, political or other opinions, property, birth, or other considerations. A supporting view of this assertion was put forward by Wright [ 122 ], who advised that PES teachers should not conceive that their task tool is technical; rather, they should aim at nurturing certain qualities required for a democratic society, such as self-confidence leavened by an agreeable humility, curiosity, courage, persistence, kindness, gentleness, care for the less fortunate, and care for other forms of life.

Before approaching the end of this cultural aspect, it is worth sounding a note of caution in the context that such a relationship can be bidirectional; that is, quality PES can help the students to learn and maintain their respective cultural characteristics and values while respecting those of others, resulting in a harmonious society. On the other hand, there is a possibility that some of such variety of cultural characteristics, e.g., religion, gender, dressing style, etc., may negatively affect PES participation at school.

In this regard, having completed their study about the influence of family and culture on PA among female adolescents from the Indian diaspora, Ramanathan and Crocker [ 123 ] revealed that female adolescents are not adequately participating in PA as males do. This was explained as due to the cultural belief that they are scared of losing their femininity while engaging in PA, and the issue of the belief that they need to stay at home supposed and be engaged with domestic duties. Similarly, religious belief is another example of a cultural characteristic that lowers the desire to participate in PA in certain societies. For example, female students from Muslim countries do not experience opportunities to effectively get involved in PA because of restrictions based on their culture, such as the dress codes; prohibited close contact with males; and lack of related facilities such as a prayer room, clean washroom with clean water, and women’s sport and fitness foundations [ 124 ].

The upshot of all of this is that some cultural characteristics and values are still preventing all school-aged children and adolescents from fully participating in PES, and this, in turn, violates the PES international charter of 21 November 1978, that allowed PES participation for all, without any kind of discrimination. Another emerging cultural aspect is the concern that some situations whereby PES is not given a top priority for its successful implementation can results in violation of cultural norms. To this end, all institutions responsible for PES should ensure adequate CPD for in-service teachers or supply trained PES teaches who have necessary PCK to help students with different cultures to learn regardless of culture differences.

4.8. PES on Sustainable Development Goals (SDGs)

It is important to signal our concern to the contribution of PES to the SDGs—a universal call to action that aims to create an equal and inclusive community with improved health by 2030. This ambitious plan consists of 17 goals with their corresponding 169 specific targets.

After the establishment of the SDGs, researchers in the field of education, particularly PES, conducted several studies to ascertain the contribution of PES in the context of SDGs and revealed that the majority of the SDGs can be achieved through the involvement of school-aged children and adolescents in quality PES. There is considerable evidence indicating that PES has a potential to create a favorable context which allows the promotion of different aspects associated with the development of the current SDGs, such as coeducation, entrepreneurship, cooperation, and respect.

The international conference of ministers and senior officials responsible for PES (MINEPS VI), UNESCO [ 125 ] established 9/17 and 36/169 goals and associated targets whereby sports-based approaches could make a significant contribution. To support the view of MINEPS VI, the study undertaken by Baena-Morales et al. [ 126 ] (pp. 7–10) explained the way in which 10/17 SDGs equivalent to 58.8% and 24/169 targets; that is, 40.5% could be achieved through PES.

Of little difference, Baena-Morales and Gonzalez-Villora, [ 127 ], who have made great strides in analyzing the role of PES to SDGs in three major dimensions, namely social, environmental, and economical dimensions, commented that SDGs should not be given much consideration as a reference, since they are too generic, but the specific targets make up SDGs.

Though some research studies raise a concern that the contribution of PES to the SDGs is slightly explored, according to Fröberg and Lundvall [ 128 ] and Baena-Morales and González-Víllora [ 127 ], others have explored the role of PA, sports, or exercises in general, Dai and Menhas [ 129 ]; focused their attention to the contribution of PES in relation to some selected SDGs, with particular aspects such as health and well-being partnership as explored by Lynch [ 130 ], it is clear that PES is a transcendental subject toward the achievement of SDGs, provided that it is given a top priority in schools worldwide. It is important to note that PES teachers should plan their lessons by linking the lesson instructional objectives with those of SDGs.

This paper provides an important opportunity to advance the understanding of the significance of PES in promoting a physically active health style in school-aged children and adolescents and the entire community, as well. It is therefore important to raise an alarm about PES enforcement to the governments of nations so as to empower PES in schools and make it serve its purpose for all students across the world.

5. Conclusions

PES has been evidenced to play a significant role in a holistic education to the extent of being considered as a backbone of the whole community in the 21st century, on account of the fact that school-aged children and adolescents are the ones that gradually become adults and later old people in their respective communities. That is to say, delivering quality PES to school-aged children is, at the same time, delivering an active lifestyle to the entire community throughout the life course. This is established based on the benefits obtainable from PES in all areas of human development, namely the cognitive, physical, affective, health, social, moral, and cultural aspects of human life, as discussed in this study.

The hindrances that impede PES from delivering all that it could offer to the school-aged children and adolescents which later affect the whole society include the following: (a) inadequately qualified teaching personnel; (b) insufficient time allocated to PES; (c) limited facilities, equipment, and materials; (d) deficit budget allocated to this subject; and (e) PE teachers detraction among others. Subsequently, a sedentary lifestyle has been mostly discussed as a pandemic among children and adolescents of this current century, resulting in suffering from hypokinetic diseases (coronary heart diseases, obesity, hypertension, osteoporosis, diabetes, etc.), as well as mental diseases such as depression and anxiety. Moreover, nowadays some students are still facing poor academic achievement, leading to increased repetition rate, drop-out rate, and ultimately on-time completion rate, an issue associated with the current sedentary lifestyle among students. From all such drawbacks of physical inactivity, one should wonder how perilous this coming society will be in the case that all of these challenges against quality PES remain unresolved.

To this end, it is important to raise these questions for the concerned leaders and related practitioners across the world, so as to come up with an effective and sustainable solutions. Apart from international charters, conventions, national policies, and international and national guidelines and endorsements, civil and private organizations (agencies) promulgated to address the promotion of PES. Considering also the fact that majority of parents’ perceptions support inclusive and quality PES for the benefits of their children, as well as the consequences of sedentary health style among all children, adults, and old people. Why are the governments of nations still inconsistent in their effort to convert their promises (agreements) of promoting PES into implementation/practice? Why are the governments of nations not willing to initiate mechanisms that aim to produce the required professionally trained personnel with the required PES resources and adequate budget? Why are school leaders still reducing or diverting allocated PES time to other subjects? Who would be held accountable for violating the universal right of quality PES for all and thwarting PES subjects from delivering all benefits claimed under its name?

“ Knowing is not enough, we must apply. Willing is not enough, we must do ”. —Goethe [ 131 ]

Acknowledgments

The effort of authors toward the successful accomplishment of this paper and funding organization is highly acknowledged.

Funding Statement

This study was funded by The National Social Science Fund of China, grant number 17BTY078.

Author Contributions

J.d.D.H. conceived the study and drafted the original manuscript. E.T. retrieved the data and checked their eligibility. K.Z. supervised the study. All authors contributed to the interpretation of the findings and discussion. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declared no potential conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• Open access
• Published: 07 September 2024

Inequity in the utilization of the home and community integrated healthcare and daily care services in older adults with limited mobility in China

• Siyu Cai 1 ,
• Qixiao Pei 2 ,
• Xuanxuan Wang 1 , 3 &
• Dongfu Qian 1 , 3  

BMC Geriatrics volume  24 , Article number:  744 ( 2024 ) Cite this article

Metrics details

This study aimed to analyze the needs and utilization of the home and community integrated healthcare and daily care services (“home and community care services” for short) among older adults in China and to investigate the inequity in services utilization.

Cross-sectional data were obtained from the 2018 China Health and Retirement Longitudinal Study. Needs and utilization rates of the home and community care services in older adults of 60 years old and above were analyzed. Binary logistic regression analysis was performed to explore the factors associated with services utilization among older adults with limited mobility. Concentration index, horizontal inequity index, and Theil index were used to analyze inequity in services utilization. Decomposition analyses of inequity indices were conducted to explain the contribution of different factors to the observed inequity.

About 32.6% of older adults aged 60 years old and above had limited mobility in China in 2018, but only 18.5% of them used the home and community care services. Among the single service utilization, the highest using rate (15.5%) was from regular physical examination. Limited mobility, age group, income level, region, self-assessed health, and depression were statistically significant factors associated with utilization of any one type of the services. Concentration indices of any one type service utilization and regular physical examination utilization were both above 0.1, and the contribution of income to inequity were both over 60%. Intraregional factor contributed to about 90% inequity of utilizing any one type service, regular physical examination and onsite visit.

Conclusions

This current study showed that older adults with needs of home and community care services underused the services. Pro-rich inequities in services utilization were identified and income was the largest source of inequity. The difference of the home and community care service utilization was great among provinces but minor across regions. Policies to optimize resources allocation related to the home and community care services are needed to better satisfy the needs of older adults with limited mobility, especially in the low-income group and the central region.

Peer Review reports

Introduction

While aging population is a global trend, China has the largest older adults population in the world, and will encounter a more rapid aging rate in the coming decade [ 1 , 2 ]. The proportion of older adults population aged 65 years old and above in China is projected to be 28.9% in 2049[ 3 ]. Compared with the young and middle-aged population, older residents have higher risk of being disable or partially disabled, which will lead to difficulty in moving around [ 3 , 4 ]. As to the traditional family concept, older adults in China are inclined to be cared by family members, especially their offspring [ 5 ]. But attributed to the One-Child Policy and the fast pace of urbanization, older adults are now facing “empty nest” – living alone with the outmigration of adult children [ 5 , 6 , 7 ]. Under such circumstance, the needs for basic health services and daily care provided at home and in the community for the aged are becoming increasingly strong.

In November 2015, the General Office of China’s State Council issued the Guidelines on Promoting the Integration of Healthcare and Older Care Services (“ Guidelines ” for short), which clearly stated that along with older care services provided in the community, health services such as regular physical examinations, home visits, family beds, community nursing and health management should be provided for older residents who have limited mobility, i.e. the ones who are disabled or partially disabled. The home and community integrated healthcare and daily care services for older adults (“the home and community care services” for short) was proposed thereafter. At the end of 2020, the home and community care services were piloted in 203 cities in five batches.

Studies on the home and community care services mainly focus on the implementation effects. Researchers found that the home and community care services had significant effect on improving life satisfaction, life quality, physical and mental health status, and health care utilization [ 8 , 9 ]. Other studies look into the demand of the home and community care services by asking older residents whether they were willing to use the services [ 10 , 11 ]. However, service demand and need are two separate concepts with distinct definitions. Partly due to difficulty in data collection, few studies examine the actual needs of the home and community care services. Up till now, there has been limited information on how large the chasm is between services needs and services utilization.

Equity in health service utilization has always been the concern of researchers and policy-makers worldwide. Previous study on inequalities in health service utilization among older adults are mainly confined to emergency service, outpatient and inpatient service [ 12 , 13 , 14 ]. It has been proved that socioeconomic status factors such as occupation type, income level, education level, and with or without medical insurance, demographic factors such as age and gender, and health need factors such as chronic diseases and limited mobility are correlated to inequity in health care utilization among older adults [ 15 , 16 , 17 , 18 , 19 , 20 ]. Long-term care services, which have some intersection with the home and community care services, have been studied from various perspectives. However, research on equity in long-term care did not provide a consensual result. Studies found pro-rich inequity in long-term care service utilization in Spain, Italy and Germany, while the result was opposite in Denmark, Netherlands, and France [ 21 , 22 ]. Studies conducted in China suggested that long-term care services reduced the inequity level of limited mobility, serious diseases, outpatient and inpatient reimbursement [ 23 ]. A study using the level of occupancy, and rehabilitation and nursing services utilization rate to assess inequity in long-term care service utilization showed that there was a pro-rich inequity in both urban and rural China [ 24 ]. There are relatively few studies on the inequity in the home and community care services in China from the level of individual service utilization. It is unknown whether the home and community care services utilization is equitably distributed among older adults with limited mobility.

This current study aimed to analyze the utilization of the home and community integrated healthcare and daily care services for older adults with limited mobility in China, and to identify the inequity in the services utilization.

Study design

This current study has a cross-sectional design. Data were drawn from the China Health and Retirement Longitudinal Study (CHARLS) wave 4 in 2018 [ 25 ]. Starting from 2011, CHARLS is a longitudinal survey with a nationally representative sample of people aged 45 years and above. Data in wave 4, 2018 were collected from 449 villages/communities in 28 provinces/municipalities. The investigators obtained response from 19,816 individuals in 11,635 households. As this current study analyzed the home and community care services for older adults with limited mobility, respondents younger than 60 years old, living in nursing institutions or hospitals, and not suffering from limited mobility were excluded. Respondents who did not answer the question of the home and community care services were then excluded. Consequently, a total of 2783 individuals were included in the analysis. Figure  1 showed the process of participants exclusion.

Flowchart on the participants exclusion process

Home and community care services needs

In accordance with the Guidelines , older adults with limited mobility, i.e. the ones who are disabled or partially disabled have needs for the home and community care services. In this current study, limited mobility was measured by activities of daily living (ADL) with the Physical Self-Maintenance Scale (PSMS). PSMS contains six items, which are dressing, bathing, eating, getting into or out of bed, using the toilet, and controlling urination and defecation, and each has answering options of “no difficulty,” “difficult but can still be done,” “have difficulties and need help,” and “unable to complete.” If the respondent selected an option other than “no difficulty” for any one item, the respondent was classified as having limited mobility and having needs for home and community care services [ 26 ]. According to the standards proposed by the China Scientific Research Center on Aging, respondents reporting difficulty in one to two, three to four and five and above items were classified into the mild, moderate, and severe group, respectively [ 27 , 28 ].

Home and community care services utilization

Utilization of the home and community care services was measured based on answers to the question – “Have you ever received the following home and community care services?” The answering options consist of 1) older adults day care, 2) regular physical examination, 3) onsite visit, 4) family bed, 5) community nursing, 6) health management and 7) entertainment. If the respondent answered “yes” to any one of the options, it is considered that the respondent had used the home and community care services.

Factors associated with home and community care services utilization

This current study followed the prevailing literature in selecting factors associated with health services utilization for older adults [ 29 , 30 ]. Besides service needs, i.e. limited mobility measured by ADL, and given the data collected in CHARLS wave 4, factors included into analysis were age group, gender, marital status, income level quintile, education level, region, urban/rural, medical insurance, self-assessed health, depression, and chronic disease number. Age was categorized into three groups, including 60–69, 70–79, 80 + years. Gender included male and female. Marital status was classified into married, single/separated/divorced, and widowed. Education level included two groups: no formal education and primary school and higher. Self-assessed health status was divided into very good, good, fair, poor, or very poor [ 31 ].

Income level

According to the Six and Seventh National Census Bulletin from National Bureau of Statistics (NBS) of China, the main sources of livelihood of older population were family support, labor income, pension, and income transfers [ 32 ]. The income was a continuous variable, calculated as the sum of family support (income from other household), labor income (income from employment, agriculture, and self-employment), pension, and income from transfers. The natural logarithm value of the income was used and further divided respondents into five groups from poorest to richest [ 16 ].

Medical insurance

China’s Basic medical insurance system consisted of the Urban Employee Basic Medical Insurance (UEBMI), the Urban Resident Basic Medical Insurance (URBMI), and the New Cooperative Medical Scheme (NCMS) for rural residents [ 33 ]. In 2016, the Urban and Rural Resident Basic Medical Insurance (URRBMI) was established to merge NCMS and URBMI officially [ 34 ]. Therefore, in addition to the three basic medical insurance, there was also URRBMI in the investigation stage of this study in 2018. The medical insurance in this study was divided into 6 categories: no insurance, UEBMI, URRBMI, URBMI, NCMS, and others.

CHARLS covered 28 provinces in China. According to the China Health Statistics Yearbook, 10 out of 28 surveyed provinces were classified into the western region, 8 provinces were in the central region, and the left 10 provinces were in the eastern region.

Depression was measured by the Center for Epidemiological Studies Depression Scale (CESD-10) [ 35 ], including two positive emotion items, five somatic symptom items, and three depressed emotion items. Respondents responded based on their feelings and behaviors last week. For each item, there are four answering options, i.e., 0 = little or no (< 1 day), 1 = not too much (1–2 days), 2 = sometimes or half the time (3–4 days), 3 = most of the time (5–7 days). The option scores for the items were added up and the two positive emotion items used reversed scoring. Respondents were divided into three groups –no depressive symptoms (a CESD-10 score < 10), depressive symptoms (10 ≤ score < 20), and depression (score ≥ 20) [ 36 ].

Chronic disease number

Fourteen specified chronic diseases including hypertension, dyslipidemia, diabetes, heart disease, stroke, chronic lung disease, asthma, liver disease, cancer, digestive disease, kidney disease, arthritis, psychiatric disease, and memory-related disease were confirmed by participant’s self-report of a physician’s diagnosis [ 37 ]. According to definition of multiple chronic diseases, the classifications of chronic disease number included no chronic diseases, 1 chronic disease, and 2 or more chronic diseases [ 38 ].

Statistical analyses

In order to analyze inequity in the utilization of home and community care services in China, a multi-stage approach was followed in Fig.  2 . In the first stage, the needs of home and community integrated healthcare and daily care services were analyzed. In the second stage, the chi-square test was used to describe disparities in service utilization between the mild, moderate, and severe limited mobility group. Binary logistic regression was used to evaluate the effect size and direction of different characteristics on the utilization of home and community care services. The results of logistic regression showed that income level and region were associated with home and community care services utilization. Therefore, in the third stage, concentration index (CI) and horizontal inequity index (HI) were used to measure the inequity in the distribution of home and community care services utilization across older adults with limited mobility. Theil index (TI) was applied to measure inequity in different regions among older adults who utilized home and community care services.

Flowchart on the analyses process

Concentration index

CI was used to measure the extent of socioeconomic-related inequity in the distribution of home and community care services utilization across older adults with limited mobility [ 39 , 40 ]. CI was calculated with reference to the concentration curve, which plotted the services utilization variable in the y-axis against the percentage distribution ranked by wealth measure in the x-axis. This current study used income level as a proxy variable for wealth measure. The CI equation was as follows:

where h represents the home and community care services utilization, μ is its mean, and r is the fractional rank of individual in the wealth measure distribution. Individual wealth was reflected by the income level, which was calculated from four parts – family support, labor income, pension, and income transfers.

Given that all the outcome variables were binary variables, the least squares regression method of indirect standardization would not guarantee the predicted values from the standardizing regression, the equation expressed as follows [ 41 ]:

where G represents the functional form for a nonlinear model using a Probit model, \(x_{j}\) and \(z_{k}\) represent the demographic characteristics/health status and socioeconomic variables respectively.

Linear approximation method to the nonlinear model was applied to decomposing CI, which was evaluated at the means to use estimates of the partial effects. A linear approximation was presented as follows:

where \(\beta_{j}^{m}\) and \(\gamma_{\kappa }^{m}\) are used to replace \(\beta_{j}^{{}}\) and \(\gamma_{\kappa }^{{}}\) for representing the partial effects of \(x\) and \(z\) , i.e. the determinants of \(y\) , and \(u_{i}\) is the implied error term, which includes approximation errors.

The CI-based HI approach was applied to quantify the inequity of home and community care services utilization. HI was measured as the variation in services utilization by rank of income level after adjusting for differences in variables such as demographic characteristics and health status[ 42 ]. Next, we conducted a decomposition of CI. The contributions of socioeconomic variables in total inequality explain actual inequities in home and community care services, as socioeconomic-related inequity is deemed unjustified or unfair[ 43 ]. If the contribution of a variable was positive, it indicated that the variable promoted pro-rich inequity.

For binary outcome variable, the number of respondents for the option less selected needed to be at least 10 times greater than the number of independent variables to use [ 44 ]. Since CI-relevant analyses included constructing the Probit model, certain home and community care services with rather low utilization rate were excluded from CI-relevant analyses.

Theil index

TI was used to measure the inequity of the home and community care services utilization in different regions and provinces. TI takes a value ranging from 0 to Log n, and it expresses highly equity when TI approaches 0 [ 45 ]. The equation below is adopted to calculate the value of total TI:

where \(Yi\) represents the ratio of number of respondents using home and community care services in different provinces to those in corresponding regions and \(Pi\) is the ratio of number of respondents in different provinces to those in corresponding regions. Therefore, TI was decomposed into two levels ( \(Tintra\) and \(Tinter\) )[ 46 ] as follows:

where \(Ti\) is the value of TI of three regions, including the eastern, central, and western region. \(Tintra\) is the intraregional distribution of services utilization in the three regions, and \(Tinter\) means interregional distribution among different regions [ 47 ]. Accordingly, we calculated the contribution of TI for different regions to analyze the source of inequity. The equations are as follows:

Inverse probability weighting (IPW) was applied to adjusting for potential selection bias. In the first step, analytical weights were produced by estimating the included probability for each individual with complete data on ADL items via binary logistic regression. In the regression analysis, the dependent variable was completeness of ADL items, where complete data were valued as 1 and incomplete ones were valued as 0. Weights were calculated as the inverse of the probabilities. The variables used to estimate weights were the same as those in the original binary logistic regression analysis of the utilization of home and community care services. Standardized mean differences (SMD) were used to assess differences in general characteristics between participants included and excluded due to missing values on ADL items [ 48 ]. In the second step, differences in the results of binary logistic regression analyses of service utilization between the original unweighted and the inverse probability-weighted samples were examined to verify the robustness of this current study. Due to missing values on covariates, samples with complete data on covariates and samples applying multiple imputation for missing data on covariates were used to estimate weights, respectively [ 49 ]. As the results of binary logistic regression analyses using unweighted and weighted samples were consistent and ADL was the screening variable for service needs in this current study, participants excluding individuals with missing data on ADL items were then included into the subsequent analyses.

Descriptive analyses of general characteristics, binary logistic regression of service utilization and concentration indices were performed by using and not using individual sample weights adjusted for non-response of individual and household, respectively. As no significant differences were found, unweighted analyses on CI decomposition and Theil indices were then carried out.

Descriptive analyses were conducted in SPSS 26.0. Inverse probability weighting and multiple imputation were conducted using R 4.2.0. All other data analyses were carried out in Stata 15.0. A two-tailed P-value below 0.05 was considered statistically significant.

General characteristics

As stated in the 2018 CHARLS survey guidelines, respondents who were younger than 50 years, and concurrently reporting very good or good health, without disabilities, not troubled with body pains, and diagnosed with no chronic diseases could skip ADL items. After the research group excluded participants younger than 60 years from this current study, there were 2291 respondents having missing data on ADL items. Compared to the ones having complete data on ADL, participants who did not provide answers to ADL questions were younger, more males, having higher socioeconomic status and reporting less health problems (in Appendix Table S1 ). After inverse probability weighting and multiple imputation, changes in SMD showed that the differences between included and excluded participants were smaller compared with the differences between the unweighted samples (in Appendix Figure S1 and S2). The results of binary logistic regression analysis using the original unweighted samples were consistent with those using inverse probability weighting for ADL (in Appendix Table S2 and S3) and those applying multiple imputation for covariates and inverse probability weighting for ADL (in Appendix Table S4 and S5).

Among the 8532 respondents in the survey who were not living in nursing institutions or hospitals, 32.6% had mild to severe limited mobility, in other words, having needs of the home and community care services. Summary statistics of the general characteristics of older adults with limited mobility were presented in Table  1 . It showed that 65.36% of older adults with needs of the home and community care services were mildly limited mobility, 81.53% were 60 to 79 years old, 60.04% were female, 69.85% were married. In term of socioeconomic status, 65.43% had no formal education, 85.88% lived in rural areas, and 68.88% participated in the medical insurance of NCMS. In respect of health status, 60.40% had at least one chronic disease, 92.53% had fair or poor self-assessed health status, and 63.49% had depressive symptoms or were assessed as patients with depression. As shown in Appendix Table S6, the unweighted analyses results of participants’ general characteristics were of no significant difference with the weighted ones using individual sample weights adjusted for non-response of individual and household in CHARLS.

Among older adults surveyed who had needs of the home and community care services, 18.5% used at least one type of such services. As shown in Table  2 , in term of the utilization rate of different service type, the highest using rate was from regular physical examination, but only about 15.5%. The mild group had a statistically significantly higher utilization rate (16.7%) than the moderate (15.2%) and severe groups (10.3%). Differences in the utilization rates of the other six service types and the rate in using any one type of such services did not vary significantly by limited mobility level. As presented in Appendix Table S7, the weighted analyses results of utilization rates were of no significant difference with the unweighted ones.

As demonstrated in Table  1 , among older adults with need of home and community care services, those with mild limited mobility had higher service utilization than the severe limited mobility groups. The older adults groups of higher services utilization were 80 + years old (21.60%), male (19.42%), widowed (20.41%), western region (21.40%), urban areas (19.34%), URRBMI (25.16%). In terms of health status, service utilization of old people with poor self-assessed health (16.70%) and depression (12.85%) was below average. 19.44% participants with multiple chronic diseases used the home and community care services.

Table 3 showed the results of the binary logistic regression analyses for any one type of the home and community care services utilization. After controlling variables of demographic characteristics, socioeconomic status, and health status, older adults with severe limited mobility were 0.50 times less likely to use the home and community care services than the ones with mild limited mobility. Compared with older adults aged 60–69 years and the ones from the poorest quintile, the older groups and the ones from the wealthier quintile were more likely to use any one type of the home and community care services. Older adults living in the central region were 0.57 times less likely to use the home and community care services than the ones in the western region. In term of self-assessed health, older adults reporting fair and poor health were 0.51 and 0.52 times less likely to use the services than the group reporting very good health, respectively. Last but not least, compared with the group without depressive symptoms, the group having depression were 0.64 times less likely to use the home and community care services. As demonstrated in Appendix Table S8, the weighted binary logistic regression results were of no significant difference with the unweighted ones.

As shown in Appendix Table S9, limited mobility, age group, income level, region, medical insurance were associated with regular physical examination service utilization. Older adults with URRBMI were 0.93 times more likely to use regular physical examination service than the group without medical insurance. While in Appendix Table S11, participants having NCMS and depression were less likely to use onsite visit service. As demonstrated in Appendix Table S10 and Table S12, the weighted binary logistic regression results were of no significant difference with the unweighted ones.

Equity in the home and community care services utilization

Table 4 presented the results of CI to measure the inequity in the utilization of the home and community care services. Since the utilization rates of family bed, community nursing, health management, older adults day care, and entertainment were quite low, the CI values for utilizing any one type of the home and community care services, regular physical examination, and onsite visit were calculated. The results demonstrated that all the three CI values were positive. In other words, there was a consistent pro-rich inequity in using the home and community care services among older adults with limited mobility. The most unequal distribution was identified in the utilization of regular physical examination (CI = 0.120), followed by the utilization of any one type of the services (CI = 0.100), while there was no evidence for inequity in onsite visit utilization. HI values for utilizing any one type of the services and regular physical examination were 0.086 and 0.106, respectively. As shown in Appendix Table S13, the weighted CI analyses results were of no significant difference with the unweighted ones.

Since the CI values for any one type service utilization and regular physical examination utilization were statistically significant, CI decomposition analyses were performed correspondingly. Figure  3 showed the top three factors with the most contribution to each service decomposition of horizontal inequities. Income was the most important factor leading to inequity, with the contribution to over 60% in both the any one type service utilization and the regular physical examination utilization. Medical insurance also contributed (18.4%) to the pro-rich inequity in utilization of regular physical examination, while only 0.2% to any one type of the services. Region made negative contributions to inequity, although with a smaller magnitude: the absolute value of contribution was less than 4% (-3.3% for any one type of the services, and -2.2% for regular physical examination). Full decomposition results of CI values were presented in Appendix Table S14-S15. According to the full decomposition results, more severe limited mobility and more serious depression conditions contributed to pro-rich inequity, which explained about 4–6% of inequities in probability of using any one type service and regular physical examination. Unobserved heterogeneities accounted for 22.9% and 7.1% of inequity in utilizing any one type service and regular physical examination, respectively.

Decomposition of horizontal inequities in the home and community care services utilization

As shown in Table  5 , the inequity of the home and community care services utilization in various provinces across regions was further analyzed. The TI value of utilizing any one type service, regular physical examination and onsite visit was 0.116, 0.148 and 0.241, respectively. According to TI decomposition values, the main inequity of services utilization was from intraregional contribution (about 90%). The western region contributed the most (35.78–45.98%) to the inequity in the home and community care services utilization. There were disparities in equity of different types of services utilization in different regions. The most inequitable regions of any one type service utilization, regular physical examination utilization, and onsite visit utilization were eastern (0.108), central (0.167), and eastern (0.363), respectively.

As found in this current study, about one-third of older adults over 60 years old had home and community care service needs, while services utilization presented obvious deficiency. Older adults with severe limited mobility, in the lower income level, having poor self-assessed health and depression, and living in the central region were less likely to use any one type of the home and community care services. There was a pro-rich inequity in the utilization of any one type of the home and community care services and the regular physical examination. The main inequity of services utilization was from intraregional contribution.

Among older adults with needs of the home and community services, most of them were female, concentrated in 60–79 years old, had lower socioeconomic levels, and reported more health problems. The home and community care services may guarantee their right of receiving convenient and appropriate basic healthcare and daily care services timely. However, the utilization rate was only 18.5% in 2018, nearly three years after the Guidelines was issued though. It might be due to the fact that the home and community care services were implemented as pilot work at the city level. Before the 2018 CHARLS was conducted, the home and community care services were delivered in only 90 pilot cities across the nation. Therefore, policymakers from different government sectors such as health, civil affairs and finance should coordinate and develop systematic measures to scale up the delivery of the home and community care services. In this current study, the utilization rate of each single service was all below 4% except regular physical examination, which was in consistence with previous studies [ 50 , 51 ]. Chinese government has implemented the National Basic Public Health Services Program since 2009, in which regular physical examination is a fixed item and must be provided free of charge once a year to older adults. As community nursing, family bed and onsite visit are not fixed items, primary health professionals have already had heavy workload, and the reimbursement policies on delivering such services were not uniform across pilot cities, primary health professionals may have insufficient motivation to provide the home and community care services. It was proved that home and community care had a slower development overall relative to institutional care [ 52 ].

This current study identified disparities in health status between older adults using and not using the home and community care services. The older adults with mild limited mobility had the highest service utilization rate of regular physical examination, while the severe limited mobility used less such service. Older people with mild limited mobility may have better health literacy than the ones with severe limited mobility and are more willing to seek preventive services actively such as regular physical examinations [ 53 , 54 , 55 ]. Older people with severe limited mobility may not have the ability to move around, and they may prefer home services to community services. But except family bed and onsite visit, the other items of the current home and community services are provided outside home. Policy makers should take into account the needs of older people who are with severe limited mobility when developing future home and community healthcare and daily care services. This current study demonstrated that the prevalence of depressive symptoms and depression was high in older adults with limited mobility. Compared to the older residents utilizing the home and community care services, the ones who did not utilize the services reported more severe conditions of depression. There were several possible explanations. Firstly, the more severe degree of depression would affect the compliance of older adults, which made it difficult for the population with limited mobility to actively seek home and community integrated healthcare and daily care services. Secondly, the current home and community care services did not address the particular needs for mental health, while the total prevalence of depressive symptoms of older adults was up to 41.1% in China in 2015 [ 56 ]. Therefore, policy makers should pay more attention to the home and community care services utilization among older adults with depression and depressive symptoms and allocate resources to improve the accessibility among these populations.

Based on results from the Logit model and CI, the utilization of any one type of the home and community care services and the regular physical examination showed pro-rich inequities. This study found the highest magnitude of pro-rich inequity in the utilization of preventive care (CI of 0.120 for regular physical examination). This is consistent with the findings in England, which showed that compared with publicly-funded healthcare services, there were higher pro-rich inequities in preventive care, such as mammography and cervical screening [ 57 ]. The result can be explained by that poorer individuals have fewer resources to invest in using preventive care to improve health level [ 58 ]. The HI further examined the effect of socioeconomic characteristics and suggested pro-rich inequities. The results of this current study proved that income was the most important factor leading to inequity, both in the utilization of any one type of home and community care services and the utilization of the regular physical examination. It is possible that better-off individuals are more aware of the home and community care services, and they have more economic resources to get access to such services. At present, the home and community care services contain both free and paid packages. Older people with lower income levels may not afford paid services. Despite that there are some free healthcare and daily care services, older adults with lower income levels may lack resources to get access to such services. Therefore, policy makers need to take into account the income level when allocating resources relevant to the home and community care services, and develop tailored interventions to satisfy the needs of diverse populations.

Medical insurance was also found to be an important variable contributing to pro-rich inequity in regular physical examination, while less contributed to any one type of home and community care services. This was similar to a study which also found that medical insurance had higher effects on preventive service utilization than primary, and tertiary care service [ 59 ]. As the CI decomposition of the medical insurance variable was positive in this current study, having medical insurance aggravated pro-rich inequity. Specifically, UEBMI provided 46.66% contribution, followed by URBMI (7.55%) and URRBMI (0.08%), and NCMS reduced pro-rich inequity, with a contribution of -38.59%. It could be explained by the fact that different types of basic medical insurance schemes in China differ in premium, financing structure and benefit design [ 30 , 60 ]. Among the previous three basic medical insurance schemes, UEBMI requires the largest premium, has the highest reimbursement rate and the widest reimbursement coverage, while NCMS is completely the opposite. Physical examination fees are covered by UEBMI, but cannot be reimbursed by URBMI or NCMS. People with NCMS are rural residents, who usually have less privileged economic status than urban residents with URBMI. In consequence, having medical insurance, especially UEBMI, could enable the older adults with better economic status to use more regular physical examination services [ 61 , 62 ]. The rather small contribution of URRBMI to pro-rich inequity indicated that the integration of URBMI and NCMS is progressing slowly. The gap between the different medical insurance systems needs to be narrowed so as to ensure that all citizens have equal access to basic public health services such as regular physical examination.

In terms of the allocation of medical resources such as medical institutions, physicians in China, the eastern region has the highest level, while the central region is higher than western [ 63 ]. However, the home and community care services utilization was highest in the western region and lowest in central in this study, which was similar to a previous study [ 64 ]. In China, there is no formal referral system, and the eastern and central regions are more prosperous than the west and have higher levels of health resources. Under such circumstances, residents in the eastern and central regions are inclined to use services provided by secondary and tertiary hospitals rather than primary health care facilities. But the home and community care services are mainly provided by primary health care facilities. That could explain why the home and community care services utilization were highest in the western region. CI decomposition analyses demonstrated that the eastern and central regions reduced the pro-rich inequity. A previous study showed that low-income patients were less likely to bypass primary care facilities than high-income patients [ 65 ]. It supports our research finding in the aspect that more older people of low-income levels in the eastern and central regions tend to use home and community care services, which are mainly provided in primary health care facilities. This finding indicates that the institutional problems of the health system should be addressed in the development of home and community integrated healthcare and daily care services. It follows that policy makers need to pay more attention to services utilization than health resource investment among home and community care services, especially in central region.

In this current study, TI values indicated a higher degree of services utilization inequity from intraregional contribution (about 90%) than from interregional contribution. The difference of the home and community care service utilization was great among provinces but minor across regions. Since many prior policies were implemented in the western region, the gap in medical resources between the eastern, central and western regions of China was gradually narrowing [ 64 ]. Equity of utilizing any one type service among different provinces was best in the western region, while equity of utilizing regular physical examination among different provinces was worst in the central region. As the home and community healthcare and daily care services were implemented by provincial governments, the findings indicated that there should be a large gap in service coverage and population coverage between different provinces. Although the western region is not as developed as the central and eastern regions, the difference in economic and social development among various western provinces is small[ 66 ]. This explains the relatively better equity of home and community care services utilization in the western region. It has been proved that the faster the economic development, the worse the inequity in health resource allocation in primary health institutions such as number of institutions, sickbeds, and physicians [ 67 ]. The inequity in health resource allocation may further lead to severer degrees of inequity in the home and community care service utilization in the central and eastern regions.

In this current study, the education levels of primary school and above reduced pro-rich inequity in utilizing home and community care services, which was consistent with previous studies [ 68 ]. Researchers found that older adults with higher education levels had higher health literacy and health awareness [ 69 ], so that they were less likely to overuse healthcare services [ 70 ].

Strengths and limitations

To the best of our knowledge, this current study may be the first to explore the needs and utilization of China’s home and community integrated healthcare and daily care services and the inequity in services utilization. This current study used a large and nationally representative sample covering 28 provinces in China. Three complementary inequity analysis methods – CI, HI, and TI were applied to improve the accuracy of the analyses of inequity.

This current study had some limitations. Firstly, this study could not verify the inferences at the causal level with cross-sectional data. The Guidelines on Promoting the Integration of Healthcare and Older Care Services (“ Guidelines ” for short) was issued in 2015. The 2018 CHARLS contained items on the home and community care services. But the latest 2020 wave did not involve such items. As a result, this current study could only analyze service utilization at the national level in 2018. Further research tracking the utilization of home and community care services are needed. Secondly, this study used the self-reported data from the respondents. Limited mobility in ADL was used to evaluate the needs of the home and community care services, thus a more systematic needs assessment system should be established to make up for the lack of self-reported data. Thirdly, participants with missing values on ADL items were excluded from the primary analyses in this current study, which may produce selection bias. Though the inverse probability weighting approach was used to verify the robustness, the possibility of selection bias could not be eliminated completely. More strict measures should be taken to guarantee response quality in future surveys. Finally, as the subjects of this study were older adults with limited mobility, service accessibility could not be analyzed from a perspective of service supply. Due to the same reason, we analyzed the equity in the utilization of home and community care services among older people with limited mobility instead of the whole population of older adults. The equity of service utilization among older people needs to be considered in subsequent studies.

This study contributed to literature on inequities in utilizing the home and community integrated healthcare and daily care services for older adults with limited mobility by using nationally representative evidence. As found in this study, there existed a contradiction of plenty of needs and insufficient utilization in the aspect of home and community care services. There was a pro-rich inequity in the utilization of different types of services. Medical insurance contributed to the pro-rich inequity in regular physical examination utilization. The difference of the home and community care service utilization was great among provinces but minor across regions. And the central region was the key area which had lower services utilization and higher degree of inequity. These findings warrant further attention to improve the accessibility of the home and community integrated healthcare and daily care services, in particular among the poorer older adults and the ones living in the central region in China, which have momentous policy implications to establish a more equitable integrated healthcare and daily care system for older adults.

Availability of data and materials

The datasets analyzed during the current study are available in the CHARLS repository, https://charls.pku.edu.cn/ .

Abbreviations

China Health and Retirement Longitudinal Study

Activities of daily living

Physical Self-Maintenance Scale

National Census Bulletin from National Bureau of Statistics

Urban Employee Basic Medical Insurance

Urban Resident Basic Medical Insurance

New Cooperative Medical Scheme

Urban and Rural Resident Basic Medical Insurance

Center for Epidemiological Studies Depression Scale

Horizontal inequity index

Inverse probability weighting

Standardized mean differences

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Acknowledgements

We thank the China Health and Retirement Longitudinal Study (CHARLS) team for providing data. This study was supported by the Public Health Policy and Management Innovation Research Team, which is an Excellent Innovation Team of Philosophy and Social Sciences in Jiangsu Universities granted by the Jiangsu Education Department. We would also like to thank all the participants in this study for their participation and collaboration. We sincerely thank the editor and the two anonymous reviewers for their constructive and helpful comments.

This study is funded by General Research Project of Philosophy and Social Sciences in Jiangsu Universities granted by the Jiangsu Education Department (grant number: 2021SJA0309).

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SC led the data analysis, interpreted the results and drafted the manuscript. PQ participated in data analysis. XW contributed to analysis framework design, results interpretation and commented on previous versions of the manuscript. DQ conceived the study and commented on previous versions of the manuscript. All authors have revised the manuscript and approved the final version.

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12877_2024_5328_moesm1_esm.docx.

Additional file 1: Appendix Table S1. Comparison of general characteristics between participants included and excluded due to ADL missing data ( n  = 10823). Appendix Figure S1. Standardized mean differences in general characteristics between included and excluded participants using samples with complete data on covariates. Appendix Figure S2. Standardized mean differences in general characteristics between included and excluded participants using samples applying multiple imputation for missing data on covariates. Appendix Table S2. Binary logistic regression analyses of the home and community care services utilization among participants with complete data on covariates based on the unweighted samples. Appendix Table S3. Binary logistic regression analyses of the home and community care services utilization among participants with complete data on covariates based on the inverse probability-weighted samples. Appendix Table S4. Binary logistic regression analyses of the home and community care services utilization among participants with multiple imputation data for missing values on covariates based on the unweighted samples. Appendix Table S5. Binary logistic regression analyses of the home and community care services utilization among participants with multiple imputation data for missing values on covariates based on the inverse probability-weighted samples. Appendix Table S6. Weighted general characteristics of older adults with limited mobility in China, 2018. Appendix Table S7. Weighted utilization rates of the home and community care services. Appendix Table S8. Weighted binary logistic regression analyses of the home and community care services utilization. Appendix Table S9: Binary logistic regression analyses of the regular physical examination service utilization. Appendix Table S10. Weighted binary logistic regression analyses of the regular physical examination service utilization. Appendix Table S11: Binary logistic regression analyses of the onsite visit service utilization. Appendix Table S12. Weighted binary logistic regression analyses of the onsite visit service utilization. Appendix Table S13. Weighted concentration indices for the home and community care services utilization. Appendix Table S14: Decomposition of concentration index for any one type service utilization. Appendix Table S15: Decomposition of concentration index for regular physical examination utilization

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Cai, S., Pei, Q., Wang, X. et al. Inequity in the utilization of the home and community integrated healthcare and daily care services in older adults with limited mobility in China. BMC Geriatr 24 , 744 (2024). https://doi.org/10.1186/s12877-024-05328-z

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DOI : https://doi.org/10.1186/s12877-024-05328-z

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Unveiling the canvas: sustainable integration of ai in visual art education.

1. Introduction

2. literature review, 2.1. ai in education, 2.2. ai in art education, 3. methodology, 4. results and analysis, 4.1. trends (rq1: what were the trends in the use of ai technologies in the field of art education between 2014 and 2023), 4.2. learning theories (rq2: what learning theories have been applied to the use of ai technologies in the field of art education), 4.3. hardware platform and application category (rq3: how are ai technologies being used in the field of art education), 4.4. evaluation (rq4: how are ai technologies being evaluated in the field of art education), 5. discussion, 5.1. implications, 5.2. research agenda and recommendations, 5.3. limitations, 6. conclusions and future research, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Share and Cite

Su, H.; Mokmin, N.A.M. Unveiling the Canvas: Sustainable Integration of AI in Visual Art Education. Sustainability 2024 , 16 , 7849. https://doi.org/10.3390/su16177849

Su H, Mokmin NAM. Unveiling the Canvas: Sustainable Integration of AI in Visual Art Education. Sustainability . 2024; 16(17):7849. https://doi.org/10.3390/su16177849

Su, Hanjun, and Nur Azlina Mohamed Mokmin. 2024. "Unveiling the Canvas: Sustainable Integration of AI in Visual Art Education" Sustainability 16, no. 17: 7849. https://doi.org/10.3390/su16177849

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