Parents influence children
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Literature Review
Parenting Practices and Children’s Physical Activity: An Integrative Review
Amy Hutchens, PhD(c), RN, CNE1, and Rebecca E. Lee, PhD2
Abstract
The purpose of this integrative review was to analyze the state of science concerning the influence of parenting practices on children’s physical activity (PA) levels. A total of 38 studies met the inclusion criteria after full-text review. The body of research is limited in experimental designs with only three studies measuring the influence of the intervention on parenting practices. Seven of the 30 quantitative studies (23.3%) found significant associations between parental role modeling of PA and children’s PA levels. Seven of the eight (87.5%) qualitative studies identified parental role modeling of PA as important in promoting children’s PA. Sixteen of the 30 (53.3%) quantitative studies found that parental support of PA was significantly associated with children’s PA. Five of the eight (62.5%) qualitative studies identified logistic support as supporting PA in children. The science could be expanded by the development of randomized controlled trials aimed at this area.
Keywords
parenting, exercise, child, review, school nursing
A dramatic reduction in the amount of physical activity (PA)
occurs between the school age and adolescent years. People
who are physically active typically live longer than those
who are not (Paffenbarger, Hyde, Wing, & Hsieh, 1986).
They also have lower rates of heart disease, stroke, type 2
diabetes, depression, and some cancers (American Heart
Association, 2013). This is also true for children. PA leads
to substantial physical and psychological health benefits
for youth (Strong et al., 2005). Parents influence children
PA levels; however, the extent and nature of this relation-
ship is not clearly defined or documented. Parenting prac-
tices include ways in which parents may shape their
children’s PA habits including increasing knowledge, mod-
eling PA, and providing accessibility to healthy PA options
(Davison & Campbell, 2005). It is critical to understand the
role that parents play in children’s activity behaviors. The
purpose of this integrative review is to analyze the state of
science concerning the influence of parenting practices on
children’s PA.
Purpose
PA is a vital component for good health and long life. It is
associated with increased fitness, improved cardiovascular
and metabolic disease risk factors, decreased likelihood of
developing type 2 diabetes, improved bone strength, and
improved mental well-being (National Physical Activity
Plan, 2014). In the United States, although 42% of children ages 6–11 years meet the recommended daily levels of 60 or
more min of moderate to vigorous PA per day, only 8% of youth aged 12- to 15 years old meet that recommendation
(National Physical Activity Plan, 2014). PA helps one main-
tain a healthy body weight (McTiernan et al., 2007). By
2030, 13 states could have obesity rates above 60% (Levi, Segal, St. Laurent, Lang, & Rayburn, 2012). Improvement in
PA levels may help to prevent obesity.
Although many factors have been shown to contribute to
children’s PA, parents have been identified as key in the
promotion of PA (O’Connor, Jago, & Barnowski, 2009).
Parents serve as important guides and role models for PA,
and they organize and fund children’s involvement in phys-
ical activities (Davison, Cutting, & Burch, 2003). Evidence
aimed at understanding the influence of parenting practices
on children’s PA levels is emerging, but the depth and
breadth are not clear. A review of parenting practices was
conducted by Xu, Wen, and Rissel (2015) but did not include
qualitative evidence (Xu, Wen, & Rissel, 2015), limiting the
depth of the review and conclusions that might be drawn
1 Fran and Earl Ziegler College of Nursing, University of Oklahoma Health
Sciences Center, Oklahoma City, OK, USA 2 Center for Health Promotion and Disease Prevention, College of Nursing
and Health Innovation, Arizona State University, Phoenix, AZ, USA
Corresponding Author:
Amy Hutchens, PhD(c), RN, CNE, Fran and Earl Ziegler College of Nursing,
University of Oklahoma Health Sciences Center, 1100 N. Stonewall,
Oklahoma City, OK 73117, USA.
Email: amy-hutchens@ouhsc.edu
The Journal of School Nursing 2018, Vol. 34(1) 68-85 ª The Author(s) 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840517714852 journals.sagepub.com/home/jsn
from it. That review found that parental encouragement and
support increase children’s PA (Xu et al., 2015). An inte-
grative review is necessary to provide unique insight through
the consideration of qualitative as well as quantitative evi-
dence. This review will critically analyze the state of science
concerning the influence of parenting practices and chil-
dren’s PA levels.
The family ecological model (FEM) and the ecological
model of physical activity (EMPA) provided the theoretical
background for the study (Davison, Jurkowski, & Lawson,
2012; Spence & Lee, 2003). The FEM was developed to
explain the relationships among the environment and parent-
ing aimed at the promotion of healthy lifestyles (Davison
et al., 2012). The FEM accounts for contextual and family
factors influencing children’s PA-related behaviors
(Davison et al., 2012). Parenting is a well-developed, main
component of the FEM. The FEM posits that to understand
behavior, one must consider the context in which the person
is living and that family provides the environment in which
behavior patterns emerge (Davison & Campbell, 2005). Par-
enting is encompassed within the EMPA as a dynamic envi-
ronmental linkage that helps to promote PA in children
(Spence & Lee, 2003). The model notes the direct and indi-
rect effects of multiple levels of the environment and their
influence on PA, and it accounts for the variations in distal
and proximal influences on PA. Distal influences of PA are
buffered by proximal factors (Spence & Lee, 2003). For
example, poor neighborhood conditions would have less
influence on children’s PA if parents were able to provide
a supportive home environment for PA.
The existing research suggests that parents influence chil-
dren’s PA by providing the context through behavior patterns
emerge (Davison & Campbell, 2005). The purpose of this
integrative review was to identify the PA parenting practices
that potentially influence children’s PA. The integrative
review is the broadest type of review; it allows for inclusion
of experimental and nonexperimental research to obtain a bet-
ter understanding of the phenomenon of concern (Whittemore
& Knafl, 2005) including problem identification, literature
search, data reduction, data display, and data comparison as
strategies to enhance rigor in integrative reviews.
Method
Eligibility Criteria
This review covered a 19-year period (1998–2017). A 19-
year period was used, as the combination of search terms did
not generate articles prior to 1998. The CINAHL, Ovid
Medline, and PubMed databases were searched in January
of 2017 for eligible studies. The search terms consisted of
combinations of “parenting,” “children,” “and “physical
activity.” Inclusion criteria for this study necessitated that
studies used qualitative or quantitative designs, were pub-
lished in English-language peer-reviewed journals, and
investigated parenting practices that influence PA in chil-
dren and adolescents. Reference lists of included papers
were examined to determine whether any of the studies met
the inclusion criteria. Studies were not considered if they did
not address parenting practices specific to PA. Studies solely
examining parenting style (without parenting practices)
were excluded. Parenting style as described by Maccoby and
Martin (1983) includes authoritarian, authoritative, permis-
sive, and uninvolved. Unpublished studies were not included
in the review. Four hundred and seven studies were initially
identified from the database searches. A total of 38 studies
met the inclusion criteria after full-text review (see flow-
chart in Figure 1).
Polit and Beck’s (2012) evidence hierarchy was used to
identify the levels of evidence for each study to determine
the strength of available evidence. The strongest level of
research ranked as Level 1 by Polit and Beck includes sys-
tematic reviews of randomized and nonrandomized control
trials. Level 2 includes single-randomized and nonrando-
mized clinical trials. The third level is systematic reviews
of correlational and observational studies. Level 4 incorpo-
rates single correlational and observational studies, and
Level 5 includes systematic reviews of descriptive and qua-
litative studies. The sixth level described by Polit and Beck
are single descriptive and qualitative studies. Last, the
seventh level entails opinions from experts.
Quality Assessment
Quantitative studies were evaluated for quality using the
Grading of Recommendations, Assessment, Development,
and Evaluation (GRADE) approach (Higgins & Green,
2011; see Table 1). This approach ranks the quality of evi-
dence as high, moderate, low, and very low. Rankings are
based on underlying methodology, and reviewers may mod-
ify the quality of a study based on an assessment of factors
that may increase or decrease the quality of the study. Ran-
domized control trials (RCTs) are ranked as high but can be
downgraded to moderate low or very low if they have lim-
itations in design, inconsistent results, imprecision of results,
or publication bias (Higgins & Green, 2011). Observational
studies are ranked as low but can be upgraded for reasons
that include a large magnitude effect. Observational studies
can also be downgraded to very low using the same criteria
used to downgrade RCTs.
A variety of methods were utilized for data collection
within the qualitative studies. Three of the studies employed
1:1 interviews for data collection (Bentley et al., 2012;
Hosseini, Anoosheh, Abbaszadeh, & Ehsani, 2013; Ickes,
Mahoney, Roberts, & Dolan, 2016). Three employed focus
groups (De Lepeleere, De Smet, Verloigne, Cardon, & De
Bourdeaudhuij, 2013; Hesketh, Hinkley, & Campbell, 2012;
Wright, Wilson, Griffin, & Evans, 2008). Nominal group
technique was used by two of the qualitative studies
(O’Connor, Cerin, et al., 2013; Suen, Cerin, & Wu, 2015).
Hutchens and Lee 69
Nominal group technique eliminates potential bias that may
occur in traditional focus groups by utilizing a structured
method, so that on person cannot dominate the discussion
(O’Connor, Cerin, et al., 2013), Only two of the qualitative
studies provided interrater reliability between coders. Those
were reported at r ¼ .87 and r ¼ .84 (De Lepeleere et al., 2013; Wright et al., 2008).
Data Extraction and Synthesis
Key concepts were identified, and methodological evidence
was evaluated (Whittemore & Knafl, 2005). The design of
this review also included principles of cross-case analysis
described by Miles, Huberman, and Saldana (2014). The
cross-case analysis seeks to enhance generalizability and
deepen understanding and explanation. This review utilized
the elements of the variable-oriented approach described by
Miles et al. (2014) through an examination of variables
within each study and their interrelationships. Research arti-
cles were read and critically reviewed several times.
Matrices were developed and analyzed for cross-case and
within-case analysis that included identifying levels of
evidence, study design, quality, sample sizes, sample char-
acteristics, measure of PA, and relevant themes.
Parental role modeling of PA included the factors of
parents’ enjoyment of PA, parents’ frequency of PA, fam-
ilies’ use of sports as recreation, and parents’ use of their
own behavior to encourage PA (Davison et al., 2003).
Studies examining parental role modeling of PA defined
it as parents’ participation, enjoyment, and recreation in
PA in front of the child. Parental modeling of behaviors
believed to increase children’s PA included parental par-
ticipation in PA alone or with their children and parents’
arranging of activities that included PA such as walking
together, visiting the swimming pool, family sports
events, and skating together (Davison & Campbell,
2005). Logistic support of PA incorporated parents enrol-
ling children in sports, attending child sporting events,
and assisting with transportation to PA events (Davison
et al., 2003). Monitoring PA included keeping track of
how much PA the child performed (Gubbels et al., 2011).
Restriction of sedentary behaviors included the parents
intentional efforts to limit the amount of time that the
child spent being sedentary.
Records identified through database searching
(n = 731) Sc
re en
in g
In cl
ud ed
E
lig ib
ili ty
Id
en ti
fi ca
ti on
Additional records identified through citations
(n = 1)
Records after duplicates removed (n =407)
Records screened (n =407)
Records excluded (n =319)
Full-text articles assessed for eligibility
(n =88)
Full-text articles excluded, no measure of parenting or children’s PA, protocols, reviews
(n = 50)
Studies included in qualitative synthesis
(n = 8)
Studies included in quantitative synthesis
(n = 30)
Figure 1. Flow diagram of study selection.
70 The Journal of School Nursing 34(1)
Results
Sample
Sample characteristics of the 38 manuscripts reviewed are
presented in Table 2. Descriptive correlational studies of the
topic were abundant, with 27 of the studies (71.1%) utilizing those methods to investigate potential association between
parenting practices and children’s PA. Eight (21.1%) of the studies were qualitative. One (2.6%) was a quasi-experimental design (Davison, Jurkowski, Li, Kranz, & Lawson, 2013), one
was a randomized controlled trial (Gerards et al., 2015), and
one was a pilot randomized controlled trial (O’Connor, Hil-
mers, Watson, Baranowski, & Giardino, 2011).
Demographic Characteristics
The children’s ages in the study ranged from infancy to 19
years old. The majority of the studies (n ¼ 19) focused on
school-aged children ages 6–12 years. Five studies focused
on preschool-aged children, and one study included infants
and preschoolers. Sample size of participants in the studies
ranged from 21 to 3,175. Studies conducted outside of the
United States were abundant. Studies conducted within the
United States focused predominantly on White families with
three studies focused on predominantly African American
samples and three on predominantly Hispanic samples (see
Table 2 for demographic characteristics of the samples).
Data Collection and Measurement
A variety of tools were used to measure the influence of
parenting practices on children’s PA levels. Nine of the 30
quantitative studies (30%) used the Activity-Related Parent- ing Practices Scale developed by Davison, Cutting, and
Burch (2003), developed specifically to measure parents’
PA-related parenting practices influencing girls’ PA. The
Activity-Related Parenting Practices Scale demonstrated
moderate to high Cronbach’s a (.61 to .86) in all studies. The Activity-Related Parenting Practices Scale was the most
frequently used tool to assess parenting practices across the
studies included in this review.
Studies not using the Activity-Related Parenting Prac-
tices Scale used a range of instruments to operationalize
parenting practices. Four studies used the Child Feeding
Questionnaire to measure parenting practices influencing
children’s activity (Arredondo et al., 2006; Gerards et al.,
2015; Gubbels et al., 2011; Remmers et al., 2014). Average
reported reliability of the Child Feeding Questionnaire was
0.67 (Remmers et al., 2014). Two of the quantitative studies
used the Parenting Strategies for Eating and Activities Scale
(PEAS). The PEAS included items about parental monitor-
ing of PA and parental reinforcement of PA. Reliability of
the PEAS for the included studies ranged from .7 to .88
(Lloyd, Lubans, Plotnikoff, Collins, & Morgan, 2014).
Ostybe and colleagues (2013) used the Home Environ-
ment Survey (HES) to measure parenting practices related to
PA in the physical, political, and sociocultural home envi-
ronment. The HES was the most detailed and inclusive
instrument used to measure parenting practices. Cronbach’s
a for items of the HES ranged between .65 and .8.
Quality
Eighteen of the 30 quantitative studies included in the
review were graded as low-quality evidence, as a result of
the majority of the studies were observational (see Table 1
for quality rankings of all quantitative studies in the review).
Accelerometers have been endorsed as the most reliable
and valid measure of PA in children (Eston, Rowlands, &
Ingledew, 1998). Fifteen of the 30 (50%) quantitative studies used accelerometers to measure children’s PA levels and 14
of the quantitative studies (46.7%%) used self-report scales as to measure PA. One (3.3%) of the quantitative studies used pedometers to measure PA (Lloyd et al., 2014).
Table 1. Quality of quantitative studies using GRADE criteria.
Studies GRADE Rating
Arredondo et al. (2006) Low Barnes, Plotnikoff, Collins, and Morgan (2015) Low Bradley, McRitchie, Houts, Nader, and O’Brien
(2011) Moderate
Crawford et al. (2010) Moderate Davison, Cutting, and Birch (2003) Low Davison et al. (2012) Low Davison, Jurkowski, Li, Kranz, and Lawson (2013) Moderate De Lepeleere, De Bourdeaudhuij, Cardon, and
Verloigne (2015) Low
Edwardson and Gorely (2010) Low Forthofer, Dowda, McIver, Barr-Anderson, and Pate
(2015) Moderate
Gerards et al. (2015) Moderate Gubbels et al. (2011) Low Heitzler, Martin, Duke, and Huhman (2006) Low Hennessy, Hughes, Goldberg, Hyatt, and
Economos (2010) Low
Jago et al. (2011) Moderate King et al. (2010) Low Lam and McHale (2014) Low Langer, Crain, Senso, Levy, and Sherwood (2014) Moderate Lloyd, Lubans, Plotnikoff, Collins, and Morgan (2014) Low Loprinzi, Schary, Beets, Leary, and Cardinal (2013) Low O’Connor, Chen, Baranowski, Thompson, and
Baranowski (2013) Low
O’Connor, Hilmers, Watson, Baranowski, and Giardino (2011)
Moderate
Ostbye et al. (2013) Low Remmers et al. (2014) Moderate Rhodes et al. (2015) Moderate Seabra et al. (2012) Low Tandon et al. (2014) Moderate Taylor, Wilson, Slater, and Mohr (2011) Low Verloigne, Van Lippevelde, Maes, Brug, and De
Bourdeaudhuij, (2012) Low
Zhao, Gao, and Settles (2013) Moderate
Hutchens and Lee 71
T a b
le 2 .
P ar
en ti n g
p ra
ct ic
es st
u d ie
s as
se ss
in g
p h ys
ic al
ac ti vi
ty o u tc
o m
es in
ch ild
re n .
A u th
o r,
Y ea
r
D es
ig n
Le ve
l o f
E vi
d en
ce Sa
m p le
P u rp
o se
P ar
en ti n g
P ra
ct ic
es V
ar ia
b le
s C
h ild
re n ’s
P h ys
ic al
A ct
iv it y
(P A
) V
ar ia
b le
s Si
gn ifi
ca n t
R es
u lt s
A rr
ed o n d o
et al
. (2
0 0 6 )
C ro
ss -s
ec ti o n al
, d es
cr ip
ti ve
co rr
el at
io n al
Le ve
l IV
n ¼
8 1 2
La ti n o
M ea
n ag
e ¼
6 ye
ar s
P ar
en ts
: 9 6 %
fe m
al e,
4 %
m al
e 4 8 %
B o ys
an d
5 2 %
gi rl
s 4 0 %
W it h
in co
m e
≤ $ 1 ,5
0 0
p er
m o n th
U n it ed
St at
es
E va
lu at
e th
e in
flu en
ce o f
p ar
en ti n g
st yl
e o n
ch ild
re n ’s
P A
an d
d ie
t
C h ild
Fe ed
in g
Q u es
ti o n n ai
re M
o n it o ri
n g
P A
: K
ee p in
g tr
ac k
o f am
o u n t
o f T
V w
at ch
ed an
d ex
er ci
se ch
ild is
ge tt
in g
P ar
en ta
l re
in fo
rc em
en t
o f P A
: P ra
is e
ch ild
fo r
b ei
n g
ac ti ve
D is
ci p lin
e th
e ch
ild fo
r sc
re en
ti m
e ac
ti vi
ti es
w it h o u t
p er
m is
si o n
Li m
it se
tt in
g: Li
m it
sc re
en ti m
e ac
ti vi
ti es
P ar
en t
co m
p le
te d
q u es
ti o n n ai
re P ar
en ta
l m
o n it o ri
n g
o f P A
w as
si gn
ifi ca
n tl y
as so
ci at
ed w
it h
ch ild
re n ’s
P A
P ar
en ta
l re
in fo
rc em
en t
o f P A
w as
si gn
ifi ca
n tl y
as so
ci at
ed w
it h
ch ild
re n ’s
P A
B ar
n es
, P lo
tn ik
o ff ,
C o lli
n s,
an d
M o rg
an (2
0 1 5 )
C ro
ss -s
ec ti o n al
, d es
cr ip
ti ve
co rr
el at
io n al
Le ve
l IV
n ¼
4 0 , m
o th
er s
an d
d au
gh te
rs M
ea n
ag e ¼
8 .8
ye ar
s P ar
en ts
: 1 0 0 %
fe m
al e
1 0 0 %
G ir
ls SE
S n o t
re p o rt
ed A
u st
ra lia
A ss
es s
m at
er n al
co rr
el at
es o f
o b je
ct iv
el y
m ea
su re
d P A
in gi
rl s
A ct
iv it y
Su p p o rt
(A C
T S)
Sc al
e Lo
gi st
ic su
p p o rt
M o d el
in g
G T
3 X
ac ce
le ro
m et
er s
Lo gi
st ic
su p p o rt
w as
p o si
ti ve
ly as
so ci
at ed
w it h
M V
P A
B en
tl ey
et al
. (2
0 1 2 )
Q u al
it at
iv e
st u d y
Le ve
l IV
n ¼
3 2 , p ar
en ts
6 –
to 8 -y
ea r-
o ld
s P ar
en ts
: 9 0 .6
% fe
m al
e, 9 .4
% m
al e
6 2 %
G ir
ls , 3 8 %
b o ys
SE S
U n it ed
K in
gd o m
Fo rm
at iv
e w
o rk
to in
fo rm
th e
co n te
n t
o f a
p ilo
t ra
n d o m
iz ed
co n tr
o l tr
ia l
(R C
T )
N A
N A
P ar
en ta
l lo
gi st
ic su
p p o rt
o f P A
fa ci
lit at
ed ch
ild ’s
P A
B ra
d le
y, M
cR it ch
ie ,
H o u ts
, N
ad er
, an
d O
’B ri
en (2
0 1 1 )
C ro
ss -s
ec ti o n al
, d es
cr ip
ti ve
co rr
el at
io n al
Le ve
l IV
n ¼
8 0 1
7 7 .3
% W
h it e
9 –
to 1 5 -y
ea r-
o ld
s P ar
en ts
: 1 0 0 %
fe m
al e
4 9 .4
% B o ys
, 5 0 .6
% gi
rl s
2 6 .1
% Lo
w SE
S U
n it ed
St at
es
E x am
in e
co n n ec
ti o n s
b et
w ee
n p ar
en ti n g
an d
o b je
ct iv
el y
m ea
su re
d P A
in 9 –
to 1 5 –
ye ar
-o ld
s
P ar
en ta
l en
co u ra
ge m
en t
o f
ch ild
P A
, p ar
ti ci
p at
in g
in P A
w it h
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