Background
Across the nation, afterschool programs (ASPs, 3-6pm) are working towards achieving national and state childhood obesity polices that define the amount of physical activity children should accumulate while the program is operating. One of the most promising policies is from the California After School Resource Center and California Department of Education. In 2009, the California Department of Education, in conjunction with the California After School Resource Center, developed the California After School Physical Activity Guidelines which state that ASPs ensure all children engage in a minimum of 30 minutes of moderate-to-vigorous physical activity (MVPA) every day the program is in session. The importance of this Physical Activity Policy is reflected in the clearly defined programmatic (e.g., every day) and behavioral (e.g., children accumulate 30min MVPA/d) goals and its ability to provide at least half of the recommended daily minutes of MVPA. Unfortunately, the amount of MVPA children accumulate while attending an ASP falls well below existing standards.  While policy adoption is necessary, without the implementation of strategies to achieve the goals outlined in policy documents, improvements in children’s MVPA is unlikely. Hence, policies are necessary, alone they are insufficient. The goal of this study was to evaluate the effectiveness of a multi-step adaptive intervention called Strategies To Enhance Practice (STEPs), designed to assist ASPs to meet the 30 minutes of MVPA/day policy goal, using a group randomized controlled trial design. The information presented represents the year 01 physical activity outcomes from baseline (spring 2013) to end of first year (spring 2014) of multi-year intervention.

Description
The design and delivery of the STEPs conceptual framework involves a multi-step, adaptive intervention approach to incorporating strategies into daily routine practice designed to increase children’s MVPA. The approach identifies essential ASP characteristics that represent fundamental building blocks which function as necessary programmatic components to achieving full integration of the strategies and eventual achievement of PA Policy. The approach considers each individual ASP as a separate setting, even when an ASP might be part of a larger organization (e.g., YMCA, Boys and Girls Club). This approach is conceptually analogous to Maslow’s hierarchy of needs and was informed from a systems framework for translating childhood obesity policies into practice in ASPs, the extensive work we’ve conducted within the ASP setting, and is consistent with the growing literature on systems capacity building.  In the spring 2013, 20 ASPs serving over 1,700 children (6-12yrs) were randomized to either an immediate (n=10) or 1-year delayed treatment group (n=10). Intervention ASPs received STEPs which focused on intentional programming of activity in each ASPs’ daily schedule, and included professional development training to establish core activity competencies of staff and ASP leaders by providing ongoing technical support/assistance. The primary outcome was accelerometry-derived proportion of children meeting the 30min/d MVPA policy.

Lessons Learned
Children attending intervention ASPs were 1.8 (odds ratio [OR], 95CI 1.3-2.5) times more likely to achieve the MVPA policy at post-assessment compared to control ASPs. Sex-specific models indicated intervention girls and boys increased from 16.7% to 21.4% (OR 2.1, 95CI 1.2-3.6) and 34.2% to 41.6% (OR 1.7, 95CI 1.1-2.6) achieving the MVPA policy, respectively, while the proportion of boys (33% to 33%) and girls (16% to 15%) in the control ASPs meeting the MVPA policy did not change. At post-assessment, 6 intervention ASPs increased the proportion of boys achieving the MVPA policy to ≥45% compared to 1 control ASP, while 3 intervention ASPs increased the proportion of girls achieving MVPA policy to ≥30% compared to no control ASPs.

Conclusions
The results of this group randomized controlled trial suggest that the STEPs approach can assist ASPs in moving towards compliance to MVPA policy goals. Additional work is required to increase the amount of activity children attending ASPs accumulate, with a concerted focus on girls.

Next Steps
The “ensure all children accumulate 30min MVPA/d” policy goal, while having considerable public health relevance, may prove difficult for ASP providers to fully meet – 100% of children achieve. Revisiting the policy language to emphasize a more achievable goal, perhaps 3 out of 4 (75%) children meeting, may assist in programs’ success. Likewise, additional efforts to identify ways to enhance activity offerings, without substantial cost, are necessary.

Support / Funding Source
Research reported in this publication was supported by the National Heart, Lung, And Blood Institute of the National Institutes of Health under Award Number R01HL112787. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.