Although many studies have illuminated the ways in which physical activity provides children with fundamental health benefits, children are not physically active to the extent that is needed [1]. Among Swedish children aged 11 years, only 21% of males and 13% of females achieve the recommended daily levels of physical activity [2]. This is even more problematic when considering the increasing problem with childhood obesity, which has risen substantially in most high-income countries over the last three decades [3]. To reach the recommended levels of activity, children could be encouraged to walk or bike to school, which are known as forms of active school transportation (AST) [4]. However, many industrial countries have seen a decline in AST among children and adolescents, and an additional decline is likely in the absence of interventions to increase AST [5,6]. Though many studies have focused on the social and environmental factors that influence children’s AST, the interventions developed have proven insufficient for promoting AST [7]. Only a few schools implemented these interventions, perhaps as a result of the disconnect between research and schools’ needs [8]. To date, several concerns about school interventions for promoting physical activity have been highlighted in reviews. It has been pointed out that research has failed to determine the contextually sensitive attributes that define successful school-based interventions [9], and rigid scientific methodologies and evaluation techniques are incompatible with societally complex issues [10]. Given the disconnect between what was intended and how AST is carried out, there is a need to analyze physical activity interventions in schools to find ways to increase their feasibility and sustainability.

This paper aims to elucidate the logic model for the problem and the solution, as well as the theoretical underpinnings of an intervention promoting AST. Intervention research is defined as the process of creating the elements of an intervention and refining those elements through a series of studies [11]. By using theory and evidence as foundations in intervention research and by presenting multiple theoretical and experiential perspectives to solve a problem [12], other research teams can be inspired to build on this or prevent future mistakes. Intervention Mapping (IM) is both a framework and a structured way of planning, implementing, and evaluating health promotion programs [13]. The theoretical underpinning of IM is the social ecological model, which states that health is a function of the individuals living in an environment. Solving a health promotion problem requires a systematic perspective. The environments include physical, social, and cultural factors, in addition to agents exercising control over these factors at each ecological level, such as interpersonal, organizational, community, or societal environments.

The aim of this paper was to present the development of an AST intervention using IM to promote children’s physical activity.

IM, a 6-step tool that maps the path from recognizing a problem to identifying a solution, was used to develop the program. The process was iterative rather than linear and the planners moved back and forth, as they gained new information and perspectives. The 6 steps include (1) logic model for the problem, (2) logic model for the solution, (3) program design, (4) program production, (5) program implementation plan, and (6) evaluation plan [13]. During program planning and execution, all planning group meetings were documented, as were field notes from every step of the process.

Program development was driven by a planning group consisting of the 2 authors with research experience concerning children and physical activity, one researcher with research experience concerning AST with a special focus on environmental engineering, 2 teachers, the principal, and the head of the municipality’s planning department.

The research project was performed in a municipality of approximately 80,000 inhabitants situated in northern Sweden. Five schools with infrastructure that could allow first-grade children to walk or bike to school were invited to participate in the study, and one school agreed to participate. This primary school had 270 schoolchildren, and the neighborhood included both apartment houses and detached houses. The 2 cohorts consisted of 45 children aged 7 to 8 years (25 males). The parents and the children were informed about the study by the authors, both face-to-face and in writing, and 42 children (23 males and 19 females) agreed to participate. All parents were also invited to participate, and 63 parents (26 fathers and 37 mothers) did so. Of the 63 parents, 46 had a college/university education and the remaining 17 had an upper secondary education. All but 2 were Swedish citizens. The distance between home and school varied between 0.2 and 6.0 km, with an average distance of 1.3 km.

Program development began by forming the planning group, which was active during the whole project.

The study was performed in accordance with the principles of the Swedish law for research ethics and the Declaration of Helsinki’s Ethical Principles for Medical Research Involving Human Subjects [14]. The study was approved by the Regional Ethical Board in Umeå, Sweden, before the start of the research project (issue date: February 9, 2016; application registration number: 2015/296-31Ö).

Once the theoretical framework was established, the planning group addressed the critical environmental and behavioral factors that were most likely to affect the outcome (Textbox 1).

Environmental factors we identified were parental knowledge of AST, attitudes toward AST, and perceived AST barriers. Therefore, during a parenting meeting, we informed parents about the benefits of physical activity for their children in terms of both health and academic performance. We also let parents discuss their doubts and fears around letting their children walk and bicycle to school and discussed solutions. In addition, we assessed parental psychological factors on an intrapersonal level using a questionnaire and discussions during this meeting. We analyzed the results from the questionnaire, determined their specific worries, and suggested solutions that were used as a starting point for program design. The questionnaire was the Modified Integrated model for Children’s Active Commuting to School, which has been shown to fit well with this model, and thus, may enable health behavior researchers to design effective interventions to promote AST [29]. Parents highlighted 2 main concerns: (1) having an accident when crossing roads with heavy traffic and (2) meeting a harmful person (stranger danger) while in transit during AST. Examples of suggested solutions used in the program were pairing children according to geographic location and encouraging them to walk or bicycle together to school. Children whose paths included heavily trafficked roads were accompanied by parents or older children.

Other behavioral factors we identified were the children’s knowledge of the benefits of AST and their motivation to engage in behavior change. To further improve the program, the next step involved collecting the children’s ideas on how to develop the program, as well as increasing their knowledge and motivation through workshops. The workshops had 3 different themes: (1) health and how physical activity affects the body and mind, (2) transportation safety (especially concerning bicycling and bullying), and (3) environmental effects of AST. The knowledge the children gained during the workshops was later used in the intervention period during standard school lessons. The workshops lasted for approximately 45 min, and information and discussions were mixed together. Examples of schoolchildren’s ideas on how to develop the program included encouraging pep talks within the pairs to increase AST use. Moreover, the children and their teachers worked collaboratively to divide the children into small groups or pairs according to where their homes were situated, constituting an empowerment approach.

To further enhance the children’s motivation to use AST, the program used gamification elements. Every day during the 4-week test period, the children put a sticker on a collective board for every kilometer they walked or bicycled between home and school, and the board’s results were integrated into lessons. For example, Mathematics class was integrated with Geography class, and the children summed the total number of kilometers achieved each week, converted kilometers into miles, and identified the locations on a map. In our previous research, we found that measuring physical activity was an effective part of a school-based intervention, and this motivated adolescents to be more physically active [33].

Another gamification element was special assignments (a challenge) that the children were encouraged to solve each week. The teachers selected the assignments, which were directly connected to the curriculum. One of the assignments on the first week was, “Which traffic signs do you encounter on your way to school?” The assignments were integrated throughout the curriculum. For example, in the Art class, the children painted pictures of traffic signs. Another assignment during the week was a security check of the bicycles in which the children followed a checklist concerning legal requirements for bicycle equipment. The second week’s special assignment was, “Count how many people you meet when walking or bicycling on your way to school,” and this assignment was integrated into the Math class. The assignment for the third week was “Bring a plastic bag and collect some litter on your way to school.” This assignment was used in a lesson concerning the environment in which the children learned about and practiced sorting litter into plastic, paper, etc. They also learned about what happens to animals and nature if the litter is left out in the environment. The fourth week’s assignment was “Notice which signs of spring you encounter on your way to school,” and this assignment was integrated into Biology class. Each Friday, the teachers summarized the assignment for the week, and a badge was awarded to the class for successful achievement.

Developing a plan for the adoption, implementation, and sustainability of the program in real-life contexts began when the needs assessment was undertaken, as careful examination of the end users’ needs contributed to program compatibility. To evaluate the program, we collected experiences from the children and teachers through focus groups. We used a semistructured interview guide to cover all aspects of the program. The opening question was “Let’s pretend I know nothing. Could you please tell me about the program?” To expand upon the answers, follow-up questions were asked. Seven focus groups with 4 to 5 children in each group and one focus group consisting of the teachers were convened. The focus groups’ discussions lasted for 16 to 45 min. Collectively, the 42 children walked or biked for 1189 km over 4 weeks, which averaged to 1.4 km for each child per school day. Bicycling contributed to at least 15 min of extra physical activity each day. The preliminary analysis of the focus groups showed that the students got motivated by the gamification elements of the intervention (ie, incorporating learning activities into assignments and measures of the use of AST), and they gained learning outcomes using time outside scheduled school hours. Furthermore, the teachers in this project found it highly rewarding to incorporate learning into AST because it made it possible to use real-life situations to teach various subjects in the curriculum.

In addition, before the intervention, we collected data on parental attitudes using the Modified Integrated model for Children’s Active Commuting to School questionnaire, and the parents answered an open letter as well, which was introduced with the following text: “You have answered a questionnaire concerning AST, including obstacles your child might experience while using AST. Describe how these obstacles can be overcome.” Two weeks after ending the intervention, a second open letter was introduced with 4 questions: “How have you as a parent experienced your child’s participation in the AST project”; “If this project is used in a different class, is there something we should do again, and are there things that should be changed”; “Which attitude towards AST did you have before the intervention, and have your attitudes changed after participating”; and “Has your own choice of travel modes changed during the project?”

The knowledge gained from these data will provide important information on key program components, which will enable us to develop sustainable health-promoting programs in a school context. We have planned to implement this program in several schools, and after implementation, feasibility and efficacy studies using cluster randomization are planned.

In this paper, we describe the systematic development of an intervention program aimed at promoting AST among children. By following the steps of the IM process, it became evident that empowerment and gamification are 2 promising avenues to consider when designing AST interventions in a school context.

Using empowerment and engaging end users was essential. By forming a planning group that included important agents who control the environmental factors, it was possible to create a promising approach for developing a sustainable physical activity program in a school that could yield positive outcomes for children. In young children, parents are the gatekeepers and they decide whether the child will use AST or other means of transportation. Thus, it is essential to involve them in the process. However, this approach is unusual. A common theme that occurs in many school-based research articles is the lack of engagement by end users in planning, implementing, and evaluating health promotion activities [25,34]. Therefore, we anticipate that one success contributor for this program was the use of empowerment.

A second important cornerstone was the use of gamification, which made it possible to integrate learning and AST through the use of school assignments, including ones that incorporated measurements of AST usage. Preliminary finding showed that gamification motivated children to use AST, a finding that is supported by Hamari et al [35]. There is an ongoing debate within gamification research as to whether specific game elements may actually undermine users’ intrinsic motivations [36]. A study examining the effects of 3 commonly employed game design elements (points, leaderboard, and levels) on users’ performance and intrinsic motivation showed that these game elements significantly increased performance but did not affect intrinsic motivation. These findings suggest that points, levels, and leaderboards by themselves do not make or break users’ intrinsic motivation in nongame contexts [36]. However, the use of gamification in schools must be further explored, as the relationship between the engaging aspect of games, learning, and physical activity is still unknown [37].

By integrating learning activities into the project, schools may be more motivated to put time and effort into implementing this program. There are complex interactions among socioeconomic, environmental, and ethnic and cultural differences, and these may be important to account for when designing effective programs to promote children’s AST. Future evaluation methods need to include a target group that displays a wider range of socioeconomic factors.

IM proved to be a valuable method to develop a structured intervention for an active school transporting intervention for children. By following the steps of the IM process, it became evident that empowerment and gamification are 2 promising avenues to consider when designing AST interventions in a school context. By engaging end users and including important agents, such as parents and teachers, who control the environmental factors, the possibility to design a sustainable program increases. In addition, gamification made it possible to integrate learning into AST, which could motivate schools to devote time and effort to implementing this program.