Can a before-school physical activity program decrease bullying victimization in disadvantaged children? The Active-Start Study

Abstract

Background/Objective: To test the effectiveness of an 8-week before-school physical activity program to reduce bullying victimization among a group of socially disadvantaged children in the Active-Start study. Method: A non-blinded randomized controlled trial was conducted in three public schools classified as highly vulnerable and located in a deprived area of Santiago (Chile). A total of 5 classes participated, totaling 170 fourth grade children. The intervention was delivered before starting the first school-class (8:00–8:30 a.m.). The program lasted for 8 weeks. Primary outcome measurement on bullying victimization was assessed by the CUBE questionnaire at baseline and post-intervention. Results: There was a statistically significant reduction in the probability of suffering physical bullying (OR= 0.18, 95% CI, 0.04-0.82; p= .027) and verbal bullying (OR=0.13, 95% CI, 0.02-0.97; p= .046) after the 8-week program. Conclusions: Participation in an 8-week before-school physical activity intervention implemented in schools located in a disadvantaged district in Santiago (Chile) resulted in lower levels of bullying victimization among study participants. The Active-Start program may be a feasible and potentially scalable intervention option to improve the climate and pro-sociality environment at schools.
Trial registration number: NCT03893149; Post-results.

Full text

Please
cite
this
article
in
press
as:
Hormazábal-Aguayo,
I.,
et
al.
Can
a
before-school
physical
activity
program
decrease
bullying
victimization
in
disadvantaged
children?
The
Active-Start
Study.
International
Journal
of
Clinical
and
Health
Psychology
(2019),
https://doi.org/10.1016/j.ijchp.2019.05.001
ARTICLE IN PRESS
+Model
IJCHP-154;
No.
of
Pages
6
International
Journal
of
Clinical
and
Health
Psychology
(2019)
xxx,
xxx---xxx
www.elsevier.es/ijchp
International
Journal
of
Clinical
and
Health
Psychology
Can
a
before-school
physical
activity
program
decrease
bullying
victimization
in
disadvantaged
children?
The
Active-Start
Study
Ignacio
Hormazábal-Aguayoa,
Omar
Fernández-Vergaraa,
Nicole
González-Calderóna,
Francisca
Vicencio-Rojasa,
Javier
Russell-Guzmánb,
Cesar
Chacana-Ca˜
nasa,
Borja
del
Pozo-Cruzc,
Antonio
García-Hermosoa,d,∗
aLaboratorio
de
Ciencias
de
la
Actividad
Física,
el
Deporte
y
la
Salud,
Universidad
de
Santiago
de
Chile,
Santiago,
Chile
bEscuela
de
Pedagogía
en
Educación
Física,
Facultad
de
Educación,
Universidad
Autónoma
de
Chile,
Chile
cInstitute
for
Positive
Psychology
&
Education,
Australian
Catholic
University,
Australia
dNavarrabiomed,
Complejo
Hospitalario
de
Navarra,
Universidad
Pública
de
Navarra
(UPNA),
IdiSNA,
Pamplona,
Navarra,
Spain
Received
25
February
2019;
accepted
2
May
2019
KEYWORDS
School
health;
Physical
exercise;
Traditional
bullying;
Student
behaviour;
Experimental
study
Abstract
Background/Objective:
To
test
the
effectiveness
of
an
8-week
before-school
physical
activity
program
to
reduce
bullying
victimization
among
a
group
of
socially
disadvantaged
children
in
the
Active-Start
study.
Method:
A
non-blinded
randomized
controlled
trial
was
conducted
in
three
public
schools
clas-
sified
as
highly
vulnerable
and
located
in
a
deprived
area
of
Santiago
(Chile).
A
total
of
5
classes
participated,
totaling
170
fourth
grade
children.
The
intervention
was
delivered
before
start-
ing
the
first
school-class
(8:00---8:30
a.m.).
The
program
lasted
for
8
weeks.
Primary
outcome
measurement
on
bullying
victimization
was
assessed
by
the
CUBE
questionnaire
at
baseline
and
post-intervention.
Results:
There
was
a
statistically
significant
reduction
in
the
probability
of
suffering
physical
bullying
(OR=
0.18,
95%
CI,
0.04-0.82;
p=
.027)
and
verbal
bullying
(OR=0.13,
95%
CI,
0.02-0.97;
p=
.046)
after
the
8-week
program.
Conclusions:
Participation
in
an
8-week
before-school
physical
activity
intervention
imple-
mented
in
schools
located
in
a
disadvantaged
district
in
Santiago
(Chile)
resulted
in
lower
levels
of
bullying
victimization
among
study
participants.
The
Active-Start
program
may
be
a
feasible
and
potentially
scalable
intervention
option
to
improve
the
climate
and
pro-sociality
environment
at
schools.
©
2019
Published
by
Elsevier
Espa˜
na,
S.L.U.
on
behalf
of
Asociaci´
on
Espa˜
nola
de
Psicolog´
ıa
Con-
ductual.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.
org/licenses/by-nc-nd/4.0/).
∗Corresponding
author.
Navarrabiomed,
IdiSNA.
Calle
de
Irunlarrea,
3,
Postal
code:
31008.
Pamplona,
Navarra,
Spain
E-mail
address:
antonio.garciah@unavarra.es
(A.
García-Hermoso).
https://doi.org/10.1016/j.ijchp.2019.05.001
1697-2600/©
2019
Published
by
Elsevier
Espa˜
na,
S.L.U.
on
behalf
of
Asociaci´
on
Espa˜
nola
de
Psicolog´
ıa
Conductual.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please
cite
this
article
in
press
as:
Hormazábal-Aguayo,
I.,
et
al.
Can
a
before-school
physical
activity
program
decrease
bullying
victimization
in
disadvantaged
children?
The
Active-Start
Study.
International
Journal
of
Clinical
and
Health
Psychology
(2019),
https://doi.org/10.1016/j.ijchp.2019.05.001
ARTICLE IN PRESS
+Model
IJCHP-154;
No.
of
Pages
6
2
I.
Hormazábal-Aguayo
et
al.
PALABRAS
CLAVE
Salud
escolar;
ejercicio
físico;
bullying
tradicional;
conducta
del
estudiante;
estudio
experimental
¿Puede
un
programa
de
actividad
física
antes
de
la
escuela
disminuir
la
victimización
por
bullying
en
ni˜
nos
desfavorecidos?
Estudio
Active-Start
Resumen
Antecedentes/Objetivo:
Evaluar
la
efectividad
de
un
programa
de
actividad
física
antes
de
la
escuela
de
ocho
semanas
para
reducir
el
bullying
en
ni˜
nos
en
desventaja
social
del
estudio
Active-Start.
Método:
Se
realizó
un
ensayo
controlado
aleatorio
no
ciego
en
tres
escuelas
públicas
vulnerables
y
ubicadas
en
Santiago
(Chile),
con
un
total
de
cinco
clases
e
incluyendo
170
ni˜
nos
de
Cuarto
Grado.
La
intervención
de
ocho
semanas
se
realizó
cinco
veces
por
semana
antes
de
comenzar
la
primera
clase
(8:00---8:30
a.m.).
La
medida
de
resultado
primaria
fue
la
victimización
por
bullying
evaluado
a
través
del
cuestionario
CUBE
al
inicio
y
después
de
la
intervención.
Resultados:
Hubo
una
reducción
estadísticamente
significativa
en
la
probabilidad
de
sufrir
bul-
lying
físico
(OR=
0,18,
IC
95%,
0,04-0,82;
p=
0,027)
y
verbal
(OR=
0,13,
IC
95%,
0,02-0,97;
p=
0,046)
después
del
programa
de
ocho
semanas.
Conclusiones:
La
participación
en
una
intervención
de
actividad
física
antes
de
la
escuela
de
ocho
semanas
implementada
en
escuelas
ubicadas
en
una
comuna
desfavorecida
en
Santiago
(Chile)
dio
lugar
a
niveles
más
bajos
de
victimización
por
bullying
entre
sus
participantes.
El
programa
Active-Start
puede
ser
una
opción
de
intervención
viable
y
potencialmente
escalable
para
mejorar
el
clima
y
el
ambiente
escolar.
©
2019
Publicado
por
Elsevier
Espa˜
na,
S.L.U.
en
nombre
de
Asociaci´
on
Espa˜
nola
de
Psi-
colog´
ıa
Conductual.
Este
es
un
art´
ıculo
Open
Access
bajo
la
licencia
CC
BY-NC-ND
(http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Despite
public
health
concerns
and
the
extensively
doc-
umented
health
benefits
of
physical
activity
(PA),
a
large
proportion
of
Chilean
children
do
not
meet
the
PA
rec-
ommendations
(Aguilar-Farias
et
al.,
2018).
Since
most
children
spend
a
majority
of
their
waking
hours
at
school,
this
environment
is
appropriate
for
the
implementation
of
preventive
interventions,
particularly
those
that
include
activities
promoting
PA
(Naylor
&
McKay,
2009).
With
the
absence
of
opportunities
for
PA
during
the
school
day,
before-school
programs
have
become
a
popular
option
to
help
children
increase
their
PA
levels
(Stylianou,
van
der
Mars
et
al.,
2016).
Although
several
recent
studies
sup-
port
a
positive
effect
of
before
school-based
PA
on
health
(Westcott,
Puhala,
Colligan,
Loud,
&
Cobbett,
2015)
and
children’s
classroom
behavior
(Stylianou,
Kulinna
et
al.,
2016),
less
literature
has
evaluated
the
social−behavioral
outcomes
of
these
programs
(Whooten,
Perkins,
Gerber,
&
Taveras,
2018).
Bullying
has
been
recognized
as
an
important
and
pervasive
problem
among
children
internationally
(Juvonen
&
Graham,
2014).
Bullying
victimization
is
present
in
different
settings,
including
the
home,
workplace,
com-
munity
settings,
through
the
use
of
electronic
devices
(i.e.,
instant
messaging,
websites,
chat
room)
(Sánchez,
Mu˜
noz-Fernández,
&
Vega-Gea,
2017),
and
mainly
in
schools
(Jiménez
&
Estévez,
2017;
Kupferman-Meik,
Burris-
Warmoth,
Rapaport,
Roychoudhury,
&
Javier,
2013).
Recent
literature
continues
to
confirm
that
many
bullying
victims
experience
serious
mental
and
physical
health
problems
(Van
Geel
et
al.,
2014).
Some
of
the
recognized
risk
factors
that
contribute
to
bullying
victimization
are:
being
seen
as
different
or
weak
(e.g.,
being
obese
or
disabled),
being
depressed,
anxious,
having
low
self-esteem
or
not
socializing.
However,
much
less
attention
has
been
given
to
the
relationship
between
health-promoting
behaviors
such
as
PA
with
bullying.
At
present,
only
few
cross-sectional
studies
have
explicitly
examined
PA
as
a
risk
factor
of
bullying
victimization,
and
findings
from
these
studies
have
been
mixed
(Demissie,
Lowry,
Eaton,
Hertz,
&
Lee,
2014;
Hertz,
Everett
Jones,
Barrios,
David-Ferdon,
&
Holt,
2015;
Peltzer
&
Pengpid,
2016;
Roman
&
Taylor,
2013;
Rudatskira
et
al.,
2014).
It
is
also
important
to
note
that
the
majority
of
previous
studies
were
conducted
in
high-income
countries
and
less
is
known
about
these
relationships
in
low
and
middle-income
nations.
Other
studies
from
high-income
countries
such
as
in
USA
(Demissie
et
al.,
2014;
Merrill
&
Hanson,
2016;
Roman
&
Taylor,
2013)
have
found
that
accumulating
the
recommended
level
of
PA
was
associated
with
lower
odds
of
being
bullied.
Henriksen,
Rayce,
Melkevik,
Due,
and
Holstein
(2016)
reported
that
self-reported
physical
inactivity
is
related
with
higher
odds
ratio
for
exposure
to
bullying
victimization
among
Danish
adolescents.
However,
according
to
these
authors
and
others
the
prevalence
of
bullying
victimization
is
higher
in
more
disadvantaged
areas
and
among
lower
social
classes
(Elgar,
Craig,
Boyce,
Morgan,
&
Vella-Zarb,
2009).
Despite
this
evidence
and
the
potential
of
PA
related
to
bullying
victimization,
the
effects
of
a
before-school
PA
pro-
gram
on
bullying
victimization
remains
unknown.
As
far
as
we
know,
the
present
randomized
controlled
trial
is
the
first
study
to
test
the
effect
of
a
PA
program
to
reduce
bul-
lying
victimization.
In
this
regard,
a
previous
study
using
play-based
structured
recess
environment
provided
posi-
tive
reductions
in
bullying
victimization
and
improvements
on
school
climate
environment
(Bleeker
et
al.,
2012).
On
the
basis
of
the
cumulative
results
of
the
above-mentioned
studies,
it
is
reasonable
to
expect
that
providing
high-
quality
PA
opportunities
could
reduce
bullying
victimization.

Please
cite
this
article
in
press
as:
Hormazábal-Aguayo,
I.,
et
al.
Can
a
before-school
physical
activity
program
decrease
bullying
victimization
in
disadvantaged
children?
The
Active-Start
Study.
International
Journal
of
Clinical
and
Health
Psychology
(2019),
https://doi.org/10.1016/j.ijchp.2019.05.001
ARTICLE IN PRESS
+Model
IJCHP-154;
No.
of
Pages
6
Before-school
physical
activity
and
bullying
victimization
3
We
hypothesized
that
participating
in
an
8-week
before-
school
PA
program,
based
on
recreational
and
cooperatives
activities,
will
result
on
self-reported
bullying
victimization
reduction
among
vulnerable
Chilean
children.
Therefore,
the
aim
of
the
study
was
to
test
the
effectiveness
of
an
8-week
before-school
physical
activity
program
to
reduce
bullying
victimization
among
a
group
of
socially
disadvan-
taged
children.
Method
Participants
The
Active-Start
study
was
a
non-blinded
randomized
con-
trolled
trial
(NCT03893149),
conducted
with
children
from
three
public
schools
classified
as
high
vulnerable
and
located
in
a
deprived
area
of
Santiago
(Chile).
All
students
in
fourth
grade
(aged
8---10
years)
within
participating
schools
were
eligible
for
participation.
A
total
of
198
children
from
the
5
classes
participating
in
the
study
were
invited
to
take
part
in
the
Active-Start
program.
Out
of
the
198
children,
only
170
(85.8%)
agreed
to
the
informed
consent
and
were
included
in
the
study.
From
these,
146
had
valid
data
for
all
mea-
surements
(baseline
and
at
the
end
of
the
intervention)
and
were
included
in
the
analysis
(intervention
group,
n=
88,
41.2%
girls,
mean=10.12±0.79
years;
and
control
group,
n=
58,
50.9%
girls,
mean=
9.97±0.51
years).
Exclusion
crite-
ria
included
(1)
children
with
some
physical
pathology
or
medical
contraindication
to
perform
physical
exercise
or
(2)
diagnosed
with
learning
disabilities
or
mental
disorders.
Both
the
intervention
and
control
group
continued
to
receive
their
standard
physical
education
lessons
(2
h/week).
Procedure
Out
of
the
21
schools
that
were
potentially
available
for
participation
in
the
study,
four
schools
showed
interest
and
were
further
informed
about
the
study.
Although
the
rest
of
the
schools
showed
interest,
time
constraints
or
other
logistic
issues
precluded
them
from
participating
in
the
study.
Finally,
only
three
schools
accepted
to
participate
in
the
program.
There
were
five
fourth-grade
classes
in
total.
Three
of
them
were
allocated
to
the
intervention
group
and
the
two
remaining
were
allocated
to
the
control
group.
These
groups
were
randomly
selected
on
the
basis
of
a
computer-generated
random
number
list.
The
random-
ization
and
intervention
occurred
at
class
level
because
of
feasibility
reasons.
The
study
protocol
was
approved
by
the
University
of
San-
tiago
Ethics
Committee
(Code
number:
938)
and
conformed
to
the
principles
of
the
Declaration
of
Helsinki.
Parents
were
asked
to
give
their
written
informed
consent
before
chil-
dren
enrolment
in
the
study.
The
parents
or
children
could
revoke
this
consent
and
withdraw
from
the
study
at
any
stage.
Intervention
The
Active-Start
intervention.
Students
participated
in
the
Active-Start
program
during
the
spring
semester
of
2018.
The
intervention
was
delivered
5
times
per
week
before
starting
the
first
school-class
(8:00---8:30
a.m.).
The
program
lasted
for
8
weeks.
Each
session
was
previously
planned
and
described
in
a
manual
dedicated
to
the
study.
These
sessions
were
designed
by
the
research
team
and
deliv-
ered
by
a
graduate
in
Sport
Sciences
who
was
not
directly
involved
in
the
research
study
and
was
previously
trained
on
how
to
deliver
the
intervention
so
that
it
was
standard-
ized
across
the
classes
allocated
to
the
intervention
group.
The
intervention
program
included
sports
games
adapted
to
the
age
of
the
participants,
playground
games,
dance
and
other
recreational
and
cooperatives
activities.
The
intensity
of
the
main
part
of
the
sessions
was
moderate-to-vigorous
according
to
a
previous
study
(García-Prieto
et
al.,
2017)
and
this
intensity
was
confirmed
by
accelerometry.
Also,
differ-
ent
activities
favoring
social
interactions
were
performed
to
facilitate
the
interactions
between
the
participants
at
the
end
of
the
sessions
(cold-down).
Each
class
allocated
to
the
intervention
group
was
exposed
to
approximately
39
Active-Start
sessions.
Instruments
and
measures
Recruitment
occurred
in
August
2018,
with
baseline
and
follow-up
measures
collected
in
September
and
Decem-
ber
2018,
respectively.
Trained
researchers
measured
the
variables
and
outcomes
of
the
study
under
stan-
dardized
conditions.
All
data
were
collected
at
the
same
time
in
the
morning,
between
8:00
a.m.
and
11:00
a.m.
Bullying
victimization.
To
assess
bullying
victimization,
this
study
used
a
scale
extracted
from
the
Single
School
Well-
being
Questionnaire-CUBE
(in
Spanish,
Cuestionario
Único
de
Bienestar
Escolar----CUBE)
(Ministerio
de
Educación
del
Perú---
MINEDU,
2013).
This
scale
has
10
items
that
explore
the
reason
for
experiencing
bullying,
however
we
excluded
the
cyberbullying
questions
(two
items)
due
to
the
age
of
the
children.
Children
were
asked
how
often
they
had
been
bul-
lied
at
school
in
the
past
seven
days
for
a
variety
of
bullying
types
including
physical
bullying;
verbal
bullying;
and
social
exclusion
bullying.
Each
bullying
type
was
assessed
using
a
4-point
Likert
scale:
none,
only
once,
twice
to
4
times,
and
5
or
more
times.
We
used
the
cut-off
point
of
‘‘twice
to
4
times’’
or
more
to
code
a
student
as
bullied
in
each
partic-
ular
category
of
bullying.
The
scale
presents
a
Cronbach’s
alpha
of
.81.
Weight
status.
Body
weight
was
measured
to
the
nearest
0.1
kg
using
a
portable
electronic
scale
(Seca
769,
Hamburg,
Germany),
and
height
was
measured
to
the
nearest
0.1
cm
using
a
portable
stadiometer
(Seca
220,
Hamburg,
Ger-
many).
Weight
status
was
classified
using
the
International
Obesity
Task
Force
age-specific
and
sex-specific
thresholds
(Cole,
Bellizzi,
Flegal,
&
Dietz,
2000).
Biological
maturation.
Peak
height
velocity
(PHV)
is
a
common
indicator
of
maturity
in
children
and
adolescents
(Malina,
Rogol,
Cumming,
Coelho
e
Silva,
&
Figueiredo,
2015).
Anthropometric
variables
(weight,
height
and
seated
height)
were
used
to
obtain
PHV
according
to
Moore’s
equa-
tions
(Moore
et
al.,
2015).
Years
from
PHV
were
calculated
by
subtracting
the
age
of
PHV
from
the
chronological
age.

Please
cite
this
article
in
press
as:
Hormazábal-Aguayo,
I.,
et
al.
Can
a
before-school
physical
activity
program
decrease
bullying
victimization
in
disadvantaged
children?
The
Active-Start
Study.
International
Journal
of
Clinical
and
Health
Psychology
(2019),
https://doi.org/10.1016/j.ijchp.2019.05.001
ARTICLE IN PRESS
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IJCHP-154;
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of
Pages
6
4
I.
Hormazábal-Aguayo
et
al.
The
difference
in
years
was
defined
as
a
value
of
maturity
offset.
Physical
activity.
Moderate-to-vigorous
PA
(MVPA)
was
assessed
using
a
GENEActiv
(ActivInsights
Ltd,
Kimbolton,
UK)
tri-axial
accelerometer
previous
to
the
program
inter-
vention.
The
GENEActiv
was
attached
to
a
polyurethane
strap,
and
worn
at
the
wrist,
like
a
watch.
Data
were
col-
lected
at
a
rate
of
85.7
Hz.
Children
were
informed
about
the
monitor
placement
and
were
asked
to
wear
the
moni-
tors
on
their
non-dominant
wrist,
continuously
for
a
period
of
seven
days
(two
weekend
days)
(Schaefer,
Nigg,
Hill,
Brink,
&
Browning,
2014).
Non-wear
time
was
assessed
over
60
minutes
windows,
using
moving
increments
of
15
minutes.
Data
were
downloaded
using
GENEActiv
software
version
1.4
and
analyzed
using
the
GGIR
software
package
for
R
(cran.r-project.org).
Children
who
achieved
on
aver-
age
of
≥60
minutes
of
MVPA
per
day
were
categorized
as
active.
Data
analysis
Conventional
summary
statistics
were
used
to
describe
par-
ticipants
in
the
study
on
key
variables
and
demographics
characteristics.
First,
we
tested
associations
between
bul-
lying
victimization,
age,
sex,
weight
status,
PHV
and
MVPA
at
baseline
by
computing
zero-order
correlations
using
Pear-
son
correlations.
Intervention
effects
were
estimated
using
logistic
regression
models
and
are
presented
as
odds
ratios
(OR)
with
95%
CIs,
with
adjustment
for
baseline
bullying
victimization
and
MVPA,
and
with
age,
sex,
weight
status,
PHV,
and
school
as
covariates.
Data
analyses
were
per-
formed
using
the
Statistical
Package
for
Social
Sciences
(Version
23.0)
software.
Statistical
significance
was
set
at
p
<
.05.
Results
The
descriptive
baseline
characteristics
of
the
study
sam-
ple
are
reported
in
Table
1.
The
compliance
with
the
intervention
program
was
83.5%.
No
statistically
significant
Table
1
Characteristics
of
the
study
sample.
Intervention
group
n=
88
Control
group
n=
58
Age
(years)
10.12
±
0.79
9.97
±
0.51
Girls
(%)
41.2
50.9
Foreign
(%)
36.4
39.3
Body
mass
index
(kg/m2)
20.44
±
3.37
20.98
±
4.98
Overweight/Obese
(%)
49.0
52.7
Peak
height
velocity
-2.10
±
1.26
-2.18
±
1.43
Moderate-to-
vigorous
physical
activity
(min/day)
74.02
±
33.12
75.77
±
26.29
Active*
(%)
58.5
61.2
Note.
Results
are
shown
as
mean
±
SD.
*
≥60
minutes
of
moderate-to-vigorous
physical
activity
per
day
of
average.
Table
2
Correlations
between
physical,
verbal,
social
exclusion
bullying,
age,
sex,
peak
height
velocity,
weight
status
and
MVPA
at
baseline.
Physical
Verbal
Social
exclusion
Physical -
Verbal .56**
-
Social
exclusion
.44**
-
Age
.00
.04
.00
Sex
-.21*
-.10
.05
Peak
height
velocity
-.21*
-.11*
.12
Weight
status
.15*
.11*
.10
MVPA
-.23
-.10
-.10
Note.
*
p
<
.05;
**
p
<
.001.
differences
were
found
between
the
intervention
and
con-
trol
group
for
any
baseline
characteristic.
As
presented
in
Table
2,
there
were
positive
zero-
order
correlations
between
physical
and
verbal
bullying
with
weight
status.
Also,
there
were
negative
correlations
between
physical
and
verbal
bullying
with
PHV,
and
sex
only
in
physical
bullying.
Table
3
shows
the
intervention
effects
on
bullying
vic-
timization
categories.
There
was
a
statistically
significant
reduction
in
the
probability
of
suffering
physical
bullying
(OR=
0.18,
95%
CI,
0.04
to
0.82;
p=
.027)
and
verbal
bullying
(OR=0.13,
95%
CI,
0.02
to
0.97;
p=
.046)
after
the
8-week
program.
Discussion
An
8-week
before-school
PA
program
resulted
in
physical
and
verbal
bullying
victimization
reductions
among
children
par-
ticipating
in
the
Active-Start
trial.
Additionally,
teachers’
feedback
indicated
that
violent
behavior
among
children
was
reduced
during
the
program,
which
can
be
considered
as
additional
benefits
of
the
program.
The
present
study,
due
to
its
design,
setting,
and
population,
may
be
replicated
in
other
elementary
schools
with
limited
budget,
which
can
positively
impact
on
students’
behavior.
Engaging
in
60
minutes
or
more
per
day
of
MVPA
is
com-
monly
recommended
for
better
health
and
quality
of
life
among
children
and
adolescents
(Piercy
et
al.,
2018).
Previ-
ous
cross-sectional
studies
reveal
that
not
meeting
these
PA
guidelines
lead
to
a
significant
risk
effect
for
bullying
vic-
timization
among
children
and
adolescents
(Demissie
et
al.,
2014;
Henriksen
et
al.,
2016).
As
far
as
we
know,
few
studies
have
analyzed
the
protection
role
of
structured
PA
on
bully-
ing
victimization.
For
example,
Garnett
et
al.
(2017)
found
that
students
reporting
lesser
amounts
of
bullying
victim-
ization
had,
on
average,
ran/walked
more
miles
compared
to
their
peers
who
reported
greater
odds
of
bullying
vic-
timization.
Similarly,
an
US
national
school-based
program,
the
Playworks
study,
which
introduces
social
emotional
learning
activities
into
play-based
structured
recess
envi-
ronment,
had
documented
positive
reductions
in
bullying
victimization
and
improvements
on
school
climate
environ-
ment
(Bleeker
et
al.,
2012).
In
this
regard,
recently
another
three
days
per
week
before-school
PA
program
resulted
on

Please
cite
this
article
in
press
as:
Hormazábal-Aguayo,
I.,
et
al.
Can
a
before-school
physical
activity
program
decrease
bullying
victimization
in
disadvantaged
children?
The
Active-Start
Study.
International
Journal
of
Clinical
and
Health
Psychology
(2019),
https://doi.org/10.1016/j.ijchp.2019.05.001
ARTICLE IN PRESS
+Model
IJCHP-154;
No.
of
Pages
6
Before-school
physical
activity
and
bullying
victimization
5
Table
3
Changes
in
bullying
prevalence
from
baseline
to
8
week’
follow-up
among
intervention
versus
control
children.
Baseline
After
intervention
Effect
estimate
Intervention
group
Control
group
Intervention
group
Control
group
Adjusted
analysis
%
%
%
%
OR
95%
CI
p
Physical
30.9
28.8
6.8
27.6
0.18
0.04
to
0.82
.027
Verbal
29.3
24.5
5.7
19.0
0.13
0.02
to
0.97
.046
Social
exclusion
17.2
11.5
11.2
8.6
0.74
0.08
to
6.66
.785
improvements
of
children
well-being
and
peer
relationship
outcomes
(Whooten
et
al.,
2018).
The
structure
PA
programs
during
school
appear
to
develop
social
skills
and
strategies
such
as
sharing,
prob-
lem
solving
and
conflict
resolution
(Pellegrini,
Huberty,
&
Jones,
1995),
potentially
fostering
a
good
school
climate
and
reducing
bullying
victimization.
Peers
in
general
also
play
a
key
role
in
bullying
victimization.
Fitzgerald,
Fitzgerald,
and
Aherne
(2012)
reported
that
PA
has
shown
to
be
related
with
peer
norms,
friendship
quality,
acceptance,
and
peer
crowd
affiliation.
Therefore,
these
aspects
could
influence
the
chil-
dren
who
are
witnessing
the
bullying
situation
to
support
the
victim.
As
suggested
by
Søndergaard
(2012),
exposure
to
bul-
lying
is
not
only
an
individual
problem,
but
also
reflects
the
social
climate
in
the
school.
Our
physical
activities
were
not
limited
to
improve
fit-
ness
or
skills,
but
also
knowledge,
following
rules,
fair
play,
respect,
tactics,
body
and
social
awareness,
personal
inter-
action
linked
to
social
effort,
conflict
resolution
skills
and
cooperative
(team)
gaming,
which
may
partially
explain
bullying
victimization
reductions
among
children
in
the
intervention
arm
of
the
study.
Our
findings
indicate
the
importance
to
ensure
that
all
children
receive
positive
PA
in
the
school
environment
(Gråstén
&
Yli-Piipari,
2019).
Addi-
tionally,
improving
of
motor
skills
(Barnett,
Van
Beurden,
Morgan,
Brooks,
&
Beard,
2009),
physical
fitness
(Garcia-
Hermoso,
Oriol-Granado,
Correa-Bautista,
&
Ramírez-Vélez,
2019),
and
self-confidence
to
engage
in
PA
during
the
school
day
(e.
g.,
during
the
recess)
among
children
in
the
intervention
group
can
also
influence
the
observed
results.
Our
study
has
several
limitations.
First,
recruitment
of
schools
was
limited
(i.e.,
3
out
of
18
schools
volunteered
to
be
part
of
this
study)
and
therefore
sample
size
may
limit
our
ability
to
reject
the
null
hypothesis.
Second,
the
present
study
took
place
in
disadvantaged
communi-
ties
and
with
fourth
grade
children,
and
therefore
results
are
not
generalizable
to
other
subgroups
of
populations.
However,
the
relatively
low
cost
and
simplicity
of
the
Active-Start
intervention
may
allow
for
an
easy
adapta-
tion
and
implementation
of
the
program
in
other
schools
environments.
Conclusions
Participation
in
an
8-week
before-school
PA
intervention
implemented
in
schools
located
in
a
disadvantaged
district
in
Santiago
(Chile)
resulted
in
lower
levels
of
bullying
victim-
ization
among
study
participants.
The
Active-Start
program
may
be
a
feasible
and
potentially
scalable
intervention
option
to
improve
the
climate
and
pro-sociality
environment
at
schools.
Funding
This
study
was
funded
by
the
Vicerrectoría
de
Investigación,
Desarrollo
e
Innovación
(Proyectos
Basales.
Grand
number:
021687GH
DAS)
of
the
Universidad
de
Santiago
de
Chile
(Chile).
AGH
is
a
Miguel
Servet
Fellow
(Instituto
de
Salud
Car-
los
III----CP18/0150).
The
funder
had
no
role
in
study
design,
data
collection
and
analysis,
decision
to
publish,
or
prepa-
ration
of
the
manuscript.
Acknowledgements
We
thank
the
children
and
adolescents
who
participated
in
the
study
and
their
parents
and
teachers
for
their
collabora-
tion.
The
authors
wish
to
thank
C.
A.
C.
Coloma,
for
revision
of
the
English
text.
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I.,
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Can
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