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Schools play a critical role in helping children lead active, healthy lives. Recess, PE classes, after-school programs, and walking or biking to and from school all have the potential to get kids moving. Research shows that kids who move more aren’t just healthier, they also tend to do better academically, behave better in class and miss fewer days of school.  Unfortunately, many schools do not offer enough opportunities for children to be active. Policy-makers, teachers and parents can use research on the benefits of school physical activity to advocate for programs and policies that help children be active before, during and after school.

Download our Schools-related Resources Sheet for the best evidence available about a variety of school-based strategies for promoting physical activity.

You can also view and download our The Role of Schools in Promoting Physical Activity infographic.

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Correlates of State Adoption of Elementary School Physical Education Policies

Date: 
03/12/2014
Description: 

Presentation at the 2014 Active Living Research Annual Conference.

Abstract: 

Background and Purpose
Physical education (PE) is a key evidence-based strategy for providing and promoting physical activity, reducing childhood obesity, and improving academic performance, yet the majority of American children do not receive the recommended weekly minutes, and standards for PE curricula, teacher certification, and student fitness assessment vary tremendously across states. In 2003, the National Cancer Institute began collecting and scoring state-level codified laws for PE in schools. These data provide a unique opportunity for researchers to examine differences and changes over time across all 50 states and Washington, DC. While previous researchers have used these data to examine associations between state-level policies and actual amount of time allocated to PE, to date, no research has attempted to predict state-level adoption of PE policies. Understanding what motivates or prohibits states from adopting PE laws is important for children’s health, especially in our current ‘new federalist’ political context wherein public health decision-making is increasingly devolved from the federal to the state level.

Objectives 
This study aimed to describe variation in states’ adoption of elementary school PE policies, with a particular focus on the roles of demographic, economic, political, and academic achievement characteristics in explaining state policy adoption in relation to PE time, curriculum standards, teacher certification, and fitness assessment requirements.

Methods
We used data from the 2003-2010 National Cancer Institute’s Classification of Laws Associated with School Students (C.L.A.S.S.) merged with state-level data from the US Census, National Center for Education Statistics, and Annie E. Casey Foundation to determine significant predictors of state adoption of  PE time, fitness assessment, staffing, and curriculum policies for elementary schools. Potential state-level predictor variables included socioeconomic, demographic, political, education system, and academic achievement characteristics. Pearson correlation coefficients and multivariate regression analyses were used to examine associations.

Results
We found tremendous variation in PE requirements across states. As of 2010, only 4 states (Florida, Louisiana, Mississippi, and Oregon) required elementary schools to provide at least 150 minutes of PE per week, and the majority of states (63%) required less than 60 minutes. In addition, the majority of states (61%) had no fitness assessment requirement/recommendation. PE curriculum standards and staffing requirements were more common; over half of states require newly-hired PE teachers to have certification, licensure, or endorsement and a college minor or major in PE. In addition, over half of states require that PE address students’ PA knowledge, behavioral and motor skills and/or fitness, and over half of states reference and incorporate curriculum standards from NASPE, a specific state agency, or another organization. Interestingly, states with more vulnerable populations (e.g. higher percent poverty, higher percentage of students eligible for free/reduced lunch, higher percentage of single mother households, lower median household income, higher percentage of black students, and higher percent black population) were more likely to have adopted stronger PE time requirements and to have incorporated curriculum standards from NASPE, a specific state agency, or another organization than states with more secure populations. With the exception of being negatively related to stronger PE staffing requirements, state-level political characteristics were not associated with the adoption of any PE laws that we examined. Finally, student academic achievement was inversely related to both PE time requirements, the incorporation of specific curriculum standards, and fitness assessment requirements. Specifically, states with a higher percentage of 4th graders scoring below the proficient level in math were more likely to have stronger PE time requirements, 4th grade math and reading scores were negatively associated with the incorporation of specific PE curriculum standards, state-level improvement in 4th grade math scores from 2003 to 2009 was negatively associated with PE time requirements, and improvement in both 4th grade math and reading scores was negatively associated with PE fitness assessment requirements.

Conclusions
States with vulnerable populations are more likely than those with economically stable populations to adopt stronger PE time and staffing requirements and to incorporate curriculum standards from NASPE, a specific state agency, or another organization. The adoption of such laws is also inversely associated with student academic performance and improvement in performance over time, suggesting a potential trade-off at the state level between investment in PE requirements and investment in student academic achievement. The results of this research suggest that more affluent states may be valuing and investing in academic achievement over PE.

Implications for Practice and Policy
This study highlights tremendous variation in state’s adoption of elementary school requirements related to PE time, staffing, curriculum, and student fitness assessment. This and other studies illustrate that time, funding, and co-existing priorities are perceived barriers to investment in PE. It may be that as a prelude to PE policy adoption, evidence illustrating how PE policies can be accomplished within the existing time and funding structures will be needed. To this end, studies that examine modifiable aspects of the structural delivery of PE (e.g. scheduled time, instructional delivery and curriculum models) are needed.

Authors: 
Shannon Monnat, PhD, Monica Lounsbery, PhD, & Nicole Smith, PhD
Location by State: 
Study Type: 

Creating an Online Platform for Healthier Changes in Latino Communities

Date: 
03/12/2014
Description: 

Presentation at the 2014 Active Living Research Annual Conference.

Abstract: 

Background and Purpose
More than 39% of Latino children ages 2-19 are overweight or obese, compared to almost 32% of all U.S. children.(1)  These high rates of obesity among Latino children are particularly alarming because Latino children currently comprise 22% of all U.S. youth—and are expected to grow to comprise 30% of the youth population by 2025.(2-3)

In response, Salud America! The Robert Wood Johnson Foundation (RWJF) Research Network to Prevent Obesity Among Latino Children launched an online network in 2007 to mobilize four sectors of society (community leaders, researchers, policymakers and media) to collaborate to reverse the obesity epidemic. In its first five years, the network recruited more than 2,000 members and fed them with innovative video, online and e-communications.(4-5)

The network also made many research advancements: 1) Developed the first-ever Latino Childhood Obesity Research Priority Agenda; 2) Funded 20 grantee researchers; 3) Developed research briefs on Latino nutrition, physical activity and media/marketing issues; and 4) Developed the “Policy Contribution Spectrum” model.(6-7)

Based on its research success and the Spectrum model, Salud America! has created and is beta-testing a unique online platform that will expand its membership and activate them to create healthy lifestyle policy change to prevent and reduce Latino childhood obesity in the areas of: active play, active spaces, better food in the neighborhood, healthier school snacks, healthier marketing, and sugary drinks.

Objectives
Salud America! is creating, populating, and recruiting members for a multi-purpose online platform, Growing Healthy Change, to serve as a clearinghouse for news, research and evidence-based informational products, ongoing prevention policies, dynamic role model stories and videos, and other resources to prevent Latino childhood obesity. We hypothesize that this online platform, which will be launched following beta-testing in Fall 2013, will increase self and collective efficacy among members of the Salud America! network to drive community efforts that will lead to reductions in Latino childhood obesity.

Methods
Salud America! surveyed its network in January 2013 to gauge the use of Salud America! products—including monthly E-alerts, quarterly E-newsletters, a website, and the proposed Growing Healthy Change online platform—and determined network members’ baseline perceived self and collective efficacy for childhood obesity change. A total of 148 individuals responded, about 10% of the network. Most respondents were between ages 50-59 (30%) and female (80%). More than half of respondents were Latino (65%).

Results
Survey results found that the majority of respondents read our quarterly and monthly newsletters and a good proportion of our younger network members were connected and using our social media fed content. In regards to efficacy for advocacy, higher levels of Salud America! engagement was associated with collective efficacy—greater confidence in organized group advocacy as a way of advancing policies to reduce Latino child obesity. This sense of collective efficacy moderately predicts intentions to engage in advocacy behaviors. Salud America! engagement levels were less strongly associated with members’ confidence in their personal ability to be an effective advocate, and this sense of self- efficacy was a very strong predictor of intentions. Based on these findings, the Growing Healthy Change online platform will work toward increasing self- and collective efficacy through peer modeling—framed through the network’s evidence-based Policy Contribution Spectrum—and tools to help individuals interested in promoting change to connect with each other and with opportunities for concerted local actions in their communities.

Conclusions
Based on network feedback, Salud America! is working to expand its web-based network through improved and more frequent communication and through the development of the Growing Healthy Change online platform—a website which will allow users to stay informed about the latest in policies related to Latino childhood obesity. Visitors to the site will be able to browse through policy changes occurring at the national, state, and local level as well as success stories, resources, and multimedia products.  By becoming a registered user, visitors will be able to submit their own success stories, stories of change happening in their community, and will be able to connect with others who are also a part of the Salud America! network. After the launch of the “Growing Healthy Change Platform,” quarterly network surveys will be sent out to evaluate the use of our Salud America! products, platform and impact on self and collective efficacy.

Implications for Practice and Policy

  1. With research and multimedia products highlighting six areas of potential change—including active play and active spaces—Salud America! will continue to lead health communication efforts to reverse childhood obesity among Latinos.
  2. The Growing Healthy Change online platform will serve as an innovative learning and communications tool to drive change and reverse Latino childhood obesity.
  3. The platform will also track changes occurring at all levels and will help determine which communities lack policies to enforce healthier lifestyles and active living initiatives, and educate on how to make changes in those areas.

 

References

  1. Ogden Cl, Carroll MD, Kit BK., Flegel KM. Prevalence of obesity and trends in body mass index among us children and adolescents, 1999-2010. JAMA: The Journal of the American Medical Association. 2012;307(5): 483-90.
  2. Humes KR, Jones A, Ramirez RR. Overview of Race and Hispanic Origin: 2010. 2011.
  3. Fry R, Passel JS. Latino Children: A Majority Are U.S.-Born Offspring of Immigrants. Washington, D.C.: Pew Research Center 2009.
  4. Ramirez AG, Chalela P, Gallion KJ, Green LW, Ottoson JM. Salud America! Developing a National Latino Childhood Obesity Research Agenda. Health Educ Behav. 2011;38: 251-260.
  5. Ramirez AG, Gallion KJ, Despres CE, Adeigbe RT. Salud America!: A National Research Network to Build the Field and Evidence to Prevent Latino Childhood Obesity. American journal of preventive medicine. 2013;44(3): S178-185.
  6. Ottoson JM, Green LW, Beery WL, Senter SK, Cahill CL, Pearson DC, et al. Policy-Contribution Assessment and Field-Building Analysis of the Robert Wood Johnson Foundation’s Active Living Research Program. American Journal of Preventive Medicine. 2009;36(2, Supplement):S34-S43.
  7. Ottoson JM, Ramirez AG, Green LW, Gallion KJ. Exploring Potential Research Contributions to Policy: The Salud America! Experience. American Journal of Preventive Medicine. 2013;44(3, Supplement): S282-S289.

 

Support / Funding Source
This research project is funded by the Robert Wood Johnson Foundation (ID 70208).

Authors: 
Rosalie Aguilar, MS, Amelie Ramirez, DrPH, MPH, Rebecca Adeigbe, MS, Cliff Despres, BJ, & Kipling Gallion, MA
Location by State: 
Population: 

Supporting Complete Streets Policy Implementation: A Low-Cost Methodology for Evaluating Pedestrian Safety and Prioritizing Investments

Date: 
03/12/2014
Description: 

Presentation at the 2014 Active Living Research Annual Conference.

Abstract: 

Background and Purpose
After years of exceeding national average crash and fatality rates, New Orleans was designated as an FHWA Pedestrian Safety Focus City in 2011 (1), forcing a renewed focus on addressing this troubling and persistent problem. Meanwhile, Complete Streets policies in this area were adopted at the state, regional, and municipal levels between 2010 and 2012 (2), presenting a critical opportunity to encourage and facilitate active transportation through policy implementation. In order to equitably prioritize these investments and maximize benefits to users, implementation of Complete Streets policy needs to be linked to the region’s safety deficiencies.

Since 2006, the University of New Orleans (in partnership with the New Orleans Regional Planning Commission) has been engaged in the development of tools for evaluating crash outcomes and improving safety for non-motorized users. The purpose of this study was to synthesize these activities into a flexible, low-cost framework for conducting a comprehensive pedestrian safety analysis, providing decision-makers with the necessary data to effectively link pedestrian safety with the built environment and create pedestrian-friendly neighborhoods, a fundamental component of a Complete Streets approach.

Description
This effort addresses local and regional agencies’ need to evaluate and prioritize pedestrian crash hot spots, and to explore the factors and circumstances associated with those crashes in specific corridors, intersections, or nodes based on readily available or easily obtained data sources. Thus, the following steps were included in this analysis:

  1. Identification and Analysis of Crash Clusters (3)
  2. Pedestrian sidewalk and intersection audits (4)
  3. Pedestrian and bicycle counts (5)
  4. Analysis of area demographics, transit, and land use context
  5. Narrative profile of fatal and severe crash incidents within target clusters
  6. Recommended Interventions

 

The result of this analysis is a concise summary of identified shortcomings in the pedestrian environment, estimated user demand, and suggested countermeasures to improve safety for a given area. This can be used as a tool to advocate for change, to provide benchmark metrics against which to evaluate future progress, to better understand some of the complexities impacting safety outcomes, and as a tool to facilitate discussion and generate support for needed policy or infrastructure interventions.

Lessons Learned
As anticipated, this study illuminated numerous infrastructure deficiencies: many facilities need to be retrofitted to comply with the American Disabilities Act, upgrades to outdated and/or non-functional equipment, and solutions needed for long-term maintenance of infrastructure once constructed. Better understanding the conditions present in a specific node, neighborhood, city, or region that affect safety outcomes can help us to more effectively prioritize the use of limited resources for near-term interventions, as well as to holistically plan for programs and policies that will guide transportation planning in the long term.

More broadly, this study also revealed a need for systemic changes in how pedestrian accommodation is provided and prioritized, and in how crash data pertaining to non-motorized users is collected, coded, and disseminated. Overall, development of a flexible, low-cost methodology for conducting localized non-motorized safety research advances communities’ efforts to improve safety outcomes, address accessibility shortcomings, and implement new and innovative ways to better implement complete streets policies. 

Conclusions and Implications
This framework for evaluating pedestrian safety, prioritizing investment, and tracking change is of potential use to many local and regional agencies, consultants, and researchers. It provides a method to efficiently guide crash analysis and mitigation, particularly in areas where access to data is constrained or non-motorized data collection programs have not yet been institutionalized.

This is especially valuable when policies have been adopted that demand such data in order to be implemented effectively, such as Complete Streets. Analysis techniques such as those described in this research can be used to 1) evaluate pedestrian conditions at the project level and identify recommended improvements, 2) prioritize investments across a jurisdiction in order to ensure that resources are applied where most needed, and 3) measure progress toward policy implementation, capturing changes in key metrics including crash totals and severity, built environment audit scores, and user volumes over time. Jurisdictions with recently adopted complete streets policies should consider incorporating multi-tool analysis frameworks such as this one in order to ensure a coordinated, data-driven approach to policy implementation.

Next Steps
The results of this study are being presented to various agencies involved in the implementation of New Orleans’ Complete Streets policies, and the researchers will continue to work with these agencies to incorporate this analysis framework in policy implementation and evaluation. Additional research is ongoing to develop a complementary analysis framework for bicyclists. Effective Complete Streets policy implementation should include coordination among stakeholders, including government agencies, developers, advocates, engineers and planning professionals, and the local community. This approach to collecting and interpreting data will be used to facilitate dialogue among these stakeholders, and ensure investments in active transportation maximize positive impacts and promote equitable outcomes for communities.

References

  1. FHWA Pedestrian and Bicycle Safety. Undated. http://safety.fhwa.dot.gov/ped_bike/. Accessed July 2, 2013.
  2. Tolford, T. Complete Streets Policy Manual. Center for Planning Excellence. 2012. http://connect.cpex.org/files/2012/08/CSmanual_FINAL.pdf. Accessed July 2, 2013.
  3. Fields, B., and T. Tolford. New Orleans Regional Pedestrian and Bicycle Crash Report, 2006-2008. July 2011. Regional Planning Commission for Orleans, Jefferson, Plaquemines, St. Bernard, and St. Tammany Parishes. http://transportation.uno.edu/phire-content/assets/files/PBRI_CrashReport2006-2008_FINAL.pdf. Accessed July 3, 2013.
  4. Renne, J.L. Auditing Neighborhoods, Streets, and Intersections for Pedestrian Safety: A Toolkit for Communities. Sept 2009. Regional Planning Commission for Orleans, Jefferson, Plaquemines, St. Bernard, and St. Tammany Parishes.Accessed July 3, 2013.
  5. Fields, B. Active Transportation Measurement and Benchmarking Development: New Orleans Pedestrian and Bicycle Count Report, 2010-2011. Gulf Coast Research Center for Evacuation and Transportation Resiliency. Jan 2012. Accessed July 3, 2013.

 

Support / Funding Source
This study was funded by the New Orleans Regional Planning Commission and Louisiana Department of Transportation and Development.

Authors: 
Tara Tolford, MURP, John Renne, PhD, & Billy Fields, PhD
Location by State: 
Population: 
Study Type: 

2013 Texas Legislator Health Perception Survey: Determining Texas State Legislators Attitudes and Support for Physical Activity-focused Policies

Date: 
03/12/2014
Description: 

Presentation at the 2014 Active Living Research Annual Conference.

Abstract: 

Background and Purpose
During the past 15 years, the Texas State Legislature has passed several progressive policies related to physical activity.  These policies have predominantly focused on requirements for coordinated school health programs, for oversight of physical activity and nutrition school policies by School Health Advisory Councils (SHACs), and for requirements for Fitnessgram testing. These policies have been supported by the Partnership for a Healthy Texas (the ‘Partnership’), a coalition composed of stakeholders focused on obesity prevention through policy change; the Partnership has made significant and incremental gains in obesity prevention-related legislation since 2001.  Evaluation of the physical activity policies implemented in Texas has shown significant changes in school environments and physical activity among public school children.

The recent turnover in the Texas Legislature because of the 2012 election has resulted in over 50% of Texas State Legislators (181 in total) being new or junior members.  Thus, many of the new legislative members and their staff have limited knowledge of previous legislative history, educational activities, and obesity issues in Texas.  This situation has created a challenge for the successful dissemination of research findings and potential for continued impact on policy actions.  Information is needed on current legislative knowledge and resources related to childhood obesity so our policy-focused partners can develop both effective communications and strategic dissemination efforts for childhood obesity-related legislation. 

Description
The primary focus of this project funded in November 2012 was to assess the knowledge, attitudes, and perceptions about obesity prevention and control measures of legislators from the 83rd Texas legislative session.  The purpose of this presentation is to present results for physical activity and related environmental changes.

This mixed-methods study included a cross-sectional quantitative survey conducted among the Texas legislature, together with qualitative interviews with a subset of legislators.  Survey questions were drawn from previously used legislative surveys and adapted specifically for the Texas environment and policy targets.  Investigators collaborated with an Advisory Board consisting of members of the Partnership, as well as other stakeholders, such as the Texas Medical Association and University governmental liaisons, to identify appropriate survey topics and legislative language/wording to develop the survey.  A complete legislator listing, including both descriptive and contact information, was compiled prior to the start of the session in January, 2013; a total of 181 legislators were identified from both the House and the Senate.  Letters of introduction and copies of the survey were distributed to all legislators, along with a link to an online survey during March, 2013.  Surveys were administered by hardcopy, online or by interview, as most convenient for the legislator/staff person.

Interview questions were created and administered to a targeted group of representatives from certain legislative committees: Appropriations, Education, Finance, Health & Human Services, Public Education, Public Health, Transportation, and the Farm to Table Caucus.

Data collection continued through the end of the third special session (August 2013).  Quantitative survey data are compiled and presented in aggregate.  Interview data were reviewed for common themes, and were triangulated with survey quantitative results.

Lessons Learned
Through the end of August, a total of 81 surveys were collected (45% response rate), with an approximately equal split between Republicans and Democrats (n = 40 and 39, respectively), and 68 House and 11 Senate members/staff; in addition, 16 interviews were completed (n = 9 House and 7 senate members/staff).  Preliminary results indicate policy recommendations with strong legislator support included improving nutrition and physical activity in early childhood programs, enhancing community environments to promote physical activity, providing more physical activity in schools, and supporting coordinated school health programs that increase physical activity and nutrition education.  Policy recommendations with little support generally included limiting sales of foods.  Legislators generally believed that the groups with the biggest role in righting obesity in Texas were individuals, parents & families, and healthcare providers; transportation groups were mentioned as the least likely to have a role in fighting obesity.  Funding and personal responsibility were listed as the biggest obstacles for passing obesity prevention-related legislation.  Most Texas legislators and their staff cited the use of online resources as a primary source of information (e.g., websites, Google).

Conclusions and Implications
In general, Texas legislators support physical activity-related policies; however, some key sectors that influence physical activity (e.g., transportation groups) are not seen as playing a key role in obesity prevention.

Next Steps
Communications to address physical activity policies should be framed to address funding and individual-level concerns. In particular, more efforts should be devoted to educating legislators about the role of transportation resources and policies in increasing physical activity. Resources for legislative action need to be available on the Internet, and search terms for websites and other resources should be optimized to allow for easy access. 

Support / Funding Source
This study was funded by the Robert Wood Johnson Foundation (Grant ID: 70474) with contributions from The University of Texas Health Science Center at Houston, School of Public Health Austin Regional Campus; the Michael & Susan Dell Center for Healthy Living.

Authors: 
Deanna Hoelscher, PhD, RD, LD, Heather Atteberry, MPH, Tiffni Menendez, MPH, Donna Nichols, MEd, Diane Dowdy, PhD, & Marcia Ory, PhD, MPH
Location by State: 
Study Type: 

In-School Physical Activity Policy and Practices in Rural, Low-income, Predominantly African American School Settings

Date: 
03/12/2014
Description: 

Presentation at the 2014 Active Living Research Annual Conference.

Abstract: 

Background and Purpose
In 2007, the Mississippi (MS) legislature acted to improve health and reduce childhood obesity through the MS Healthy Students Act (SB 2369) (1), which mandates school-age students engage in specific amounts of in-school physical activity (ISPA).  However, schools in predominantly rural, low-income, racially concentrated communities are not meeting the provisions of the law (2) and there are increasing disparity gaps in childhood obesity between black (27.8%) and white (19.5%) students.(3)   As facilitators linked to successful ISPA policy implementation are identified, the dissemination of best practices is pertinent and likewise, as barriers are revealed there is a need to develop and disseminate effective ISPA strategies.(4) Furthermore, it is important that these outcomes are identified as relevant by legislators and inform future decisions related to childhood ISPA, obesity and health disparities. Thus, the purpose of this investigation was to disseminate evidence-based findings to state policy-makers, and to identify and disseminate ISPA best practices at the district- and school-levels in the MS Delta.

Objectives
1) Translate and disseminate research findings to inform key lawmakers in the MS legislature; 2) Identify ISPA best practices at the school- and district-levels in the MS Delta; and 3) Foster collaboration among researchers, state agencies, and organizations that focus on reducing childhood obesity and child health disparities.

Methods
A collective case study (5) approach was used to investigate ISPA policy implementation in the MS Delta. Qualitative data collection procedures included: 1) two focus groups with school principals (n=11) and two interviews with district-level administrators to understand an administrator’s role in developing and implementing ISPA policy, to identify barriers to implementation, and to reveal best practices; 2) two focus groups  with PE teachers (n=21) to identify barriers to implementing PE curricula and to reveal best practices; and 3) two focus groups with elementary school students (n=16) to identify ISPA that students typically engage in and want to engage in, and to identify how frequently students are engaged in and want to engage in ISPA. Audio recordings were transcribed, verified, and consensus rendered by two co-investigators. Transcendent themes that emerged from the transcripts were identified within and across groups to provide a detailed description of factors that influence ISPA policy.(5)

Results
Students recognized the importance of ISPA for academic achievement, enjoyed having physical activity integrated into classroom learning, and valued PE and recess. Students were most interested in dance activities, organized competitions (i.e., obstacle courses, races), and sports (males). Some students believed they had ample time for ISPA while others did not.

PE teachers identified four primary barriers to implementing PE curricula: 1) schedules do not provide ample time for students to learn, practice, and master skills, 2) limited monetary resources for staff support, space, and equipment, and 3) lack of state, district, and school administrative support for PE, which 4) fosters a school-wide devaluing of the PE teacher and PE program. However, PE teachers that demonstrated successful ISPA practices had strong support from their principals and reported having strong community partnerships/collaborations.

The principals agreed that academic achievement is their primary concern but also recognized the importance of ISPA in achieving academic success and acknowledged funding as a barrier. Principals with successful ISPA programs reported having strong community partnerships/collaborations and those with less successful programs reported rurality and location as challenges to creating community partnerships/collaborations. Other successful practices included policies that incorporated “brain breaks” and physical activity into classroom instruction.

The district curriculum coordinator was aware of the state ISPA requirements and took responsibility to ensure the requirements were met by communicating with principals and conducting PE evaluations. The superintendant was familiar with the requirements but believed it was the responsibility of the principals to develop and implement ISPA policy.

Conclusions
Most district- and school-level personnel in the MS Delta recognize the importance of ISPA for students’ academic success but acknowledge there are formidable challenges. Despite these challenges, there are schools in the MS Delta with successful ISPA programs. A key concept is having a school principal that serves as an “ISPA champion” and plays an integral role in creating a school culture that values ISPA. The principals’ excitement for ISPA inspires teachers and students to support ISPA.

Implications for Practice and Policy
The most rural schools need assistance in developing and implementing ISPA policy to provide the most disadvantaged, at-risk students with sufficient ISPA opportunity. Policy-makers need to be informed of successes and challenges of the MS Healthy Students Act.  There is urgent need for specific policy to address rural and racial child health disparities. Advising policy-makers of the evidence-based outcomes will help them make informed decisions regarding ISPA and childhood obesity polices. Thus, we have a meeting to discuss the results of this project with MS legislators and other stakeholders in October 2013. In addition to the results of this project, we will be able to share the outcomes of this meeting at the ALR annual meeting.

References

  1. Mississippi Healthy Students Act, SB 2369 Available at http://billstatus.ls.state.ms.us/documents/2007/pdf/SB/2300-2399/SB2369SG.pdf. Accessed September 3, 2013.
  2. Gamble A. The role of policy on children’s in-school physical activity in the Mississippi Delta. Unpublished doctoral dissertation, The University of Mississippi, University.
  3. Kolbo JR, Zhang L, Fontenot Molaison E et al. Prevalence and trends in overweight and obesity among Mississippi public school students, 2005-2011. J MSMA. 2012; 53: 140-146.
  4. Gamble A, Waddell D, Ford MA, Bentley JP, et al. Obesity and health risk of children in the Mississippi Delta. J Sch Health. 2012; 82: 478-483.
  5. Creswell JW. (2013). Qualitative inquiry and research design: Choosing among five approaches (3rd ed.). Thousand Oaks: Sage Publications, Inc.

 

Support / Funding Source
This investigation is funded by Active Living Research Translation Awards (RWJF #67132).

Authors: 
Abigail Gamble, PhD, CHES & Jeffrey Hallam, PhD, CHES
Location by State: 
Study Type: 

Accelerometer Assessment of Children’s Physical Activity Levels at Summer Camps

Date: 
03/12/2014
Description: 

Presentation at the 2014 Active Living Research Annual Conference.

Abstract: 

Background and Purpose
Approximately 14.3 million American children attend summer camps(1), which may last up to 10 hours/day for up to 12 weeks.  There is some evidence that fitness gains and body weight reductions achieved from school-based interventions are not maintained during the summer months (2,3).  The evidence base is growing for the impact out-of-school time (OST) programs can have on childhood obesity prevention, but little is known about children’s activity levels in summer camps.  Two assessments using systematic observation found that 20-25%(4) and 28%(5) of children were engaged in walking or vigorous activity at any time during camp hours.  However, no known studies to date have assessed daily summer camp activity levels using accelerometers.

Objectives
To assess baseline levels of physical activity via accelerometer among elementary school children attending summer camps, and to inform adaptation of an evidence-based afterschool obesity prevention program [Out of School Nutrition and Physical Activity (OSNAP) Initiative(6)] to the summer camp setting.

Methods
This study used a cross-sectional and repeated measures design to assess accelerometer-measured physical activity levels among children ages 5-12 attending 5 summer camps in Boston, Massachusetts, from July-August 2013.  Children attending 5 camps selected via convenience sample were recruited to wear accelerometers during camp hours for one week (5 days).  Each consenting child wore an accelerometer (Actigraph GT3X/GT3X+, Pensacola, FL) on an elastic belt on the hip throughout the camp day except during swimming periods.  Data collectors visited camps each day to observe activities and distribute and collect accelerometers.  Primary outcomes were daily minutes of moderate-to-vigorous physical activity (MVPA) and vigorous physical activity (VPA) accumulated overall and occurring in bouts.  Vertical axis intensity counts captured using the low-frequency extension were converted into minutes spent in MVPA and VPA using the Freedson(7) age-specific 1-minute cut points for children, at MET thresholds of 4 and 6 METs for moderate and vigorous activity, respectively.  Linear regression analysis was used to estimate differences in daily activity levels according to demographic characteristics, adjusting for clustering of children within camps.  Associations between daily activity levels and physical activity opportunities observed will be investigated to determine sources of daily variation in activity levels within children.

Results
Among 184 children eligible and consenting to participate in the study, 153 children (83%) wore monitors on at least 2 days for at least 5 hours/day.  Camp duration was 7.5-10 hours/day.  Children were on average 7.6 (SD 1.4) years of age, and 47% were female.  Children were multi-ethnic (8% White non-Hispanic, 37% Black non-Hispanic, 27% Hispanic/Latino, 3% Asian, 25% multi-racial/other race/ethnicity).  Children wore monitors for an average of 4.2 (SD 0.9) days for 8.9 (SD 1.1) hours/day.  On average, children attending summer camps accumulated 78.0 (SD 37.5) minutes/day MVPA overall, with 38.8 (SD 31.1) minutes/day in bouts.  They accumulated 17.0 (SD 13.4) minutes/day VPA overall, with 3.2 (SD 6.8) minutes/day in bouts.  Among 77 children with 5 monitored days, 23 (30%) met recommendations for 60 minutes/day MVPA on all 5 days, and 22 (29%) met recommendations on 4 days.  Since activity levels during swimming periods were not captured via accelerometer, these results likely underestimate actual physical activity levels.  In multiple regression analysis accounting for clustering within camps, results showed that boys were more active than girls (Beta=11.9 minutes/day MVPA overall; p=0.01), and younger children were more active than older children (B=9.1 minutes/day MVPA per year of age; p<0.001).  No differences by race/ethnicity were found.  Activity levels differed significantly between camps (p<0.001; range 54.9-118.3 minutes/day MVPA), and were highly clustered among children within camps (intraclass correlation=0.37 for MVPA overall).

Conclusions
Elementary school children attending summer camps in Boston, Massachusetts achieved, on average, daily recommended levels of MVPA during camp hours.  Males and younger children engaged in higher levels of physical activity.  Both males and females achieved overall MVPA levels (86.3 and 68.6, respectively) during the camp day similar to national objectively-measured averages above 4 METs (95.4 and 75.2 for 6-11 year old males and females)(8).  Analysis of variation in activity levels according to duration and types of physical activities offered to children attending camps will provide further insight into potential areas of intervention.  Additional research will assess foods and beverages consumed in summer camps and thus describe overall energy balance among children during the summer months.

Implications for Practice and Policy
This study lays the groundwork for adapting successful OST interventions designed for traditional afterschool programs to full day summer camps.  Results indicate that activities in summer camps may need to be targeted to engage females and older children in recommended levels of physical activity.  As community leaders work to disseminate evidence-based physical activity and nutrition interventions in Boston and nationwide, these results will help them set realistic goals.  In Boston, academic and city agency partners will use these results to inform dissemination of the OSNAP intervention via the Racial and Ethnic Approaches to Community Health (REACH) Obesity and Hypertension Demonstration Project.

References

  1. Afterschool Alliance. America After 3PM Special Report on Summer: Missed Opportunities, Unmet Demand. Washington, DC: Afterschool Alliance; 2010.
  2. Carrel AL, Clark RR, Peterson S, Eickhoff J, Allen DB. School-based fitness changes are lost during the summer vacation. Arch Pediatr Adolesc Med. 2007;161(6):561-564.
  3. Gutin B, Yin Z, Johnson M, Barbeau P. Preliminary findings of the effect of a 3-year after-school physical activity intervention on fitness and body fat: The Medical College of Georgia Fitkid Project. International Journal of Pediatric Obesity: IJPO. 2008;3(Suppl 1):3-9.
  4. Beets MW, Weaver RG, Beighle A, Webster C, Pate RR. How physically active are children attending summer day camps? J Phys Act Health. 2013;10:850-855.
  5. Zarrett N, Sorensen C, Skiles B. Environmental and social-motivational contextual factors related to youth physical activity: systematic observations of summer day camps. International Journal of Behavioral Nutrition and Physical Activity. 2013;10:63.
  6. Harvard School of Public Health Prevention Research Center. The Out of School Nutrition and Physical Activity Initiative (OSNAP). Available at: www.osnap.org. Accessed September 4, 2013.
  7. Freedson P, Pober D, Janz KF. Calibration of accelerometer output for children. Med Sci Sports Exerc. 2005;37(11):S523-S530.
  8. Troiano RP, Berrigan D, Dodd KW, Masse LC, Tilert T, McDowell M. Physical activity in the United States measured by accelerometer. Med Sci Sport Exerc. 2008;40(1):181-188.

 

Support / Funding Source
Support for this project was provided by cooperative agreements with the Centers for Disease Control and Prevention [CDC U48DP001946]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the CDC.

Authors: 
Jessica Barrett, MPH, Angie Cradock, ScD, Steven Gortmaker, PhD, Rebekka Lee, ScD, Catherine Giles, MPH, & Rosalie Malsberger, BA
Location by State: 

Evidence Review: Reporting Guidelines to Enhance Evidence-Based Practice

Date: 
03/12/2014
Description: 

Presentation at the 2014 Active Living Research Annual Conference.

Abstract: 

Background and Purpose
Over the past decade, public and private U.S. funders have invested in research and evaluation to understand the most effective, feasible, and sustainable strategies to combat childhood obesity. This evidence is used to aid practitioners and decision-makers at the organizational or agency, community, state, or national levels in selecting strategies to best fit their health, economic, environmental, and social circumstances. Current comprehensive review systems (such as the Community Guide and the Cochrane Review) provide guidance to practitioners and decision-makers interested in implementing change; yet, keeping up with the vast amount of research and evaluation data generated in the field is an ongoing challenge. In turn, decision-makers often rely on insufficient evidence as well as reviews focused more on assessing the internal validity of study results without complementary evaluation of the external validity (e.g., reach, implementation fidelity, and sustainability) associated with intervention impacts.

Objectives
The aims of the review were to: 1) develop and apply replicable methods – modeled after respected formal systematic evidence review systems (e.g., Community Guide) – to assess the scientific and grey literature addressing policy and environmental strategies for reducing obesity levels, improving healthy eating, and/or increasing physical activity among youth aged 3-18 years of age; 2) summarize these findings using easy-to-read evidence maps that identify effects/associations related to obesity/overweight, physical activity, and nutrition/diet outcomes; and 3) classify intervention strategies, based on their effectiveness and population impact using  ratings ranging from “effective” (recommended for use) to “promising” and  “emerging” (recommended for further testing).

More comprehensive reviews stemming from improved reporting and review standards may provide a better platform for practitioners, decision-makers, evaluators, and researchers to understand the effectiveness and impact of interventions to prevent childhood obesity.

Methods
Investigators created a protocol to systematically identify, abstract, review, and rate evidence from a variety of sources (e.g., intervention evaluations, associational studies). The ratings were designed to reflect effectiveness (study design, intervention duration, effects or associations) and population impact (effectiveness plus potential population reach –participation or exposure and representativeness) of multicomponent and complex interventions, with a particular emphasis on impacts for racial/ethnic and lower-income populations of greatest need for these interventions. Over 2,000 documents, published between January 2000 and May 2009 in the scientific and grey literature, were identified (2008-2009) and systematically analyzed (2009-2012). Studies focused on policy or environmental strategies to reduce obesity/overweight, increase physical activity, and/or improve nutrition/diet among youth (3-18 years). Related articles (i.e., those corresponding to an intervention or associational study) were grouped together into a “study grouping.” Study groupings were categorized into one or more of 24 independent strategies to increase healthy eating or active living. Investigators used the RE-AIM framework (i.e., Reach, Effectiveness, Adoption, Implementation, and Maintenance) both to assess internal and external validity, and to derive standard, objective ratings of intervention effectiveness and impact for each study grouping.  The assigned ratings were then entered into an Access database to generate reports for a range of indicators (e.g., outcomes assessed, intervention components, funding sources) within and across strategies.

Results
From 396 study groupings (600 independent articles) included in this analysis, 142 (36%) were intervention evaluations and 254 (64%) were associational studies. Reported outcomes varied, including physical activity (45%), obesity/overweight (25%), nutrition (18%), sedentary behavior (2%), and other shorter-term proxies, such as trail use or fruit and vegetable purchases (10%). Evidence for intervention effectiveness was reported in 56% of the evaluation, and 77% of the associational, study groupings. Among intervention evaluations, 49% had sufficient data for population impact ratings, and only 28% qualified for a rating of “high population impact.” Moreover, only 15% of intervention evaluations had sufficient data to provide high-risk population impact ratings, and only 9% qualified for a rating of “high” for high-risk population impact.

Conclusions
This study employed ways to build on assessments of internal validity to rate effectiveness and to evaluate external validity to rate population impact, thereby helping to characterize and synthesize practice-based evidence. Among studies eligible to receive ratings, investigators noted significant variation in methods, measures, and reporting. Other studies failed to report on key elements required for assessing the internal or external validity of intervention effects and impacts, including those elements specified by the RE-AIM framework.

Implications for Practice and Policy
This work helps to accelerate the pipeline of evidence, moving from evaluability assessments to syntheses of effectiveness and impact to rigorous expert review systems. To increase real-time evidence review and dissemination efforts, researchers and evaluators have to agree on standardized indicators and reporting mechanisms in all peer-reviewed publications. This analysis identifies several indicators that can be incorporated consistently to improve review and reporting standards, thus enhancing the ability of evaluators to assess internal and external validity.  In response, these efforts can more systematically enhance the knowledge base and improve recommendations for practitioners and decision-makers interested in childhood obesity prevention in both the general population and in high-risk populations.

Support / Funding Source
Support for this study was provided by a series of grants from the Robert Wood Johnson Foundation (#63675, 65518, 67413).

Authors: 
Allison Kemner, MPH, Melissa Swank, MPH, & Laura Brennan, PhD, MPH
Location by State: 

Accountable Care Organizations, Physicians, and Private-Public Partnerships for Active Design

Date: 
03/12/2014
Description: 

Presentation at the 2014 Active Living Research Annual Conference.

Abstract: 

Background and Purpose
How can the Affordable Care Act benefit the neighborhood built environment? Accountable care organizations (ACO’s), a relatively new model of healthcare delivery, may be a critical component to the multidisciplinary partnerships necessary to build healthy communities. The model, which rewards doctors and hospitals for health maintenance rather than health care provision, is a logical outgrowth of health reform measures designed to improve patient outcomes and reduce costs. In the wake of the new law, as health care systems reinvent themselves to maintain viability and profitability, ACOs will continue to proliferate across the nation, presenting a timely opportunity for organizations looking to move active living research into built realities.

As defined by a task force of the American Academy of Family Physicians, an ACO is “a primary care-based collaboration of health care professionals and health care facilities that accept joint responsibility and accountability for the quality and cost of care provided to a defined patient population.” They are a relatively new phenomenon; currently ACOs now number more than 400, but cover four million Medicare enrollees and millions more people with private insurance.

Because ACO profits will be tied to keeping their patient population healthy, and recruiting health-minded patients to select their ACO, these healthcare organizations are expected to play increasingly active roles in promoting community health by aligning with public health, local government community development departments and community-based organizations(CBO. Armed with new growing empirical evidence on the relationship between the built environment and preventative health behavior, ACO’s can potentially help fund and direct neighborhood health programs such as tree planting initiatives, retrofitting parks with walking paths, or sponsoring farmers’ markets. ACO’s can also influence community and regional health by providing grant match dollars needed for transportation projects to improve transit access, close sidewalk gaps and advance complete streets. Supporting this type of neighborhood, community and regional development can further improve health, supports the work of physicians in encouraging consumers to increase physical activity, and reduces the need for costly medical care.

Description
This research collaboration which includes professionals and researchers at Sutter Eden Medical Center, Kaiser Permanente, and Design 4 Active Sacramento (D4AS), a community-based organization and advisory council in Sacramento, California, discusses the nature and growth of ACO’s in the wake of the Affordable Care Act, and its potential for active living initiatives. Using our current work in Sacramento as a case study, we outline how we have already established partnerships between public health, local government, and community based organizations to fund and implement interventions in the built environment.

Lessons Learned
D4AS has already begun the process of implementing active design guidelines and programs such as improved access to transit, complete streets initiatives, sidewalk gaps closures, and a Safe Routes to School initiative. We discuss how they have leveraged these guidelines and programs into existing infrastructure and new development projects by strategically reaching out to other agencies and organizations and focusing on the monetary benefits of active design, from attaching “price tags” to and quantifying benefits of these programs for outside investment, to finding and structuring federal grant match programs.

Conclusions and Implications
By examining both the challenges and potential in healthcare provider partnerships and quantifying costs and benefits of active design implementation, we aim to lead a practical discussion on beginning to translate the vast research on active living into realized projects in a new era of healthcare healthcare delivery.

Next Steps
We outline our current and future efforts in integrating healthcare providers, with a specific focus on ACO’s, in the wake of the Affordable Care Act.

References

  1. Lowery, A. (2013, April 24). A Health Provider Strives to Keep Hospital Beds Empty. New York Times, p. A1.
  2. Bovbjerg, R. R., Ormond, B. A., & Waidmann, T. A. (2011). What Directions for Public Health under the Affordable Care Act? Urban Institute Health Policy Center.
  3. Rittenhouse DR, Shortell SM, Fischer ES. Primary care and accountable care – two essential elements of delivery-system reform. N Engl J Med 2009; 361(24): 2301-2303.
  4. Shortell, S. M. (2013). Bridging the Divide Between Health and Health. JAMA, 309(11), 1121-1122.

 

Support / Funding Source
The Design 4 Active Sacramento team was one of 20 teams nationwide chosen this year by the US Centers for Disease Control to participate in the National Leadership Academy for the Public’s Health.

Authors: 
Sara Carr, MArch, MLA, Edie Zusman, MD, FACS, FAANS, MBA, & Judy Robinson
Location by State: 
Population: 

Newly Implemented Comprehensive School Physical Activity Programs and Children’s Physical Activity

Date: 
03/11/2014
Description: 

Presentation at the 2014 Active Living Research Annual Conference.

Abstract: 

Background and Purpose
A whole-of-school approach, such as Comprehensive School Physical Activity Program (CSPAP), continues to be endorsed as a promising way to increase the daily physical activity (PA) levels of children via five integral components: (a) physical education, (b) PA during school, (c) PA before/after school, (d) staff involvement and (e) family/community engagement. In 2012, the National Association for Sport and Physical Education [NASPE] created a professional development (PD) program to equip current teachers with the knowledge, skills and confidence to spearhead the implementation of at least one new school PA program beyond the CSPAP component of physical education. Understanding the PA influence of having a trained PA champion in schools with the greatest risk of obesity can provide timely evidence for the effectiveness and utility of similar training efforts nationwide.

Objectives
The purpose of this quasi-experimental, cluster non-randomized controlled study was to evaluate the impact of the CSPAP PD program on changes in the school PA levels of underserved 9-14 year-old children for one academic year post training.

Methods
A stratified sample of 16 certified full-time elementary (n = 9) and middle school (n = 7) teachers of high poverty (72% free and reduced lunch) and minority (81% African American) students were allocated to either a full treatment (n = 7, CSPAP trained in summer 2012 plus customized PD assistance), partial treatment (n = 4, CSPAP trained in summer 2012 only), or waitlist control (n = 5, CSPAP trained in summer 2013) group based on teaching experience and gender. Teachers recruited a random sample of students (M = 25) from their entire rosters of 9-14 year olds resulting in a total of 351 participating children (130 full treatment, 108 partial treatment, 113 waitlist control) who wore accelerometers for 2-5 consecutive school days during fall 2012 (baseline) and spring 2013 (post). Teachers and students completed weekly logs describing the types and timing of PA opportunities during each data collection period. The primary PA outcomes that served as the dependent variables were: (a) percentage of time spent in PA, (b) percentage of time spent in moderate-to-vigorous PA (MVPA), and (c) percentage of time spent in sedentary behavior over the five day period. The independent variables were the conditions of waitlist control, partial treatment, and full treatment.

Results
Of the 351 sampled children, 298 had full baseline/post data sets on all study variables. ANOVA revealed no significant differences between the partial and full treatment groups with regard to portion of time spent in PA (p = .76), MVPA (p = .63), and sedentary behavior (p = .63). Accordingly, the treatment conditions of full and partial were collapsed for the remaining analyses. ANOVA results revealed that all post PA mean values (e.g., Mcontrol = 20.00%, SD = 0.09; Mtreatment = 21.06%, SD = 0.05) were significantly lower than the pre PA mean values (e.g., Mcontrol = 26.32%, SD = 0.02; Mtreatment = 23.46%, SD = 0.05, p < .001). However, MANOVAs revealed [F(1, 297) = 28.95; p <.001; R2adjusted = .09] that the total proportion of children’s PA time in schools with a partially or fully CSPAP trained teacher was significantly higher than children with a non-CSPAP trained teacher. This finding was also true for the proportion of time spent in MVPA, F(1, 297) = 23.96, p < .001; R2adjusted = .08. The portion of time dedicated to sedentary behavior significantly decreased in children housed in schools with either a full or partial treatment teacher compared to control teachers, F(1, 297) = 28.00, p < .001, R2adjusted = .09.

Conclusions
Although all participating students significantly declined in the total amount of PA and MVPA over the school year, perhaps because of weather or mandated testing schedules, students taught by full or partial treatment teachers participated in significantly more PA and MVPA and significantly less sedentary behavior than the students taught by control teachers as a result of the increased number of PA opportunities offered by the CSPAP PD. These findings are encouraging, but effect sizes were small. We believe follow-up data may reveal differences between students in schools with a partial and full treatment teacher as some of the full effects of teacher's effort may not be observed until year 2 and 3 of CSPAP implementation.

Implications for Practice and Policy
This study provides preliminary evidence for the effectiveness of PD programs on improving school PA. We hope this work provides further evidence to advance the development and impact of national training efforts underway surrounding school PA champions (e.g., Physical Activity Leader). Consequently, it is our expectation that this research will inform policy decisions related to CSPAP implementation and its implications for evidence-based PD and increased student PA levels in schools.

Support / Funding Source
This research was funded by the Robert Wood Johnson Foundation, Active Living Research Building Evidence to Prevent Childhood Obesity Rapid Response Grant, Round 3.

Authors: 
Russell Carson, PhD, Ann Pulling, MS, Allison Raguse, MS, Hannah Calvert, MEd, Elizabeth Glowacki, MA, Darla Castelli, PhD, & Aaron Beighle, PhD
Location by State: 

A Multi-level Analysis Showing Associations between School Neighborhood and Child Body Mass Index

Date: 
03/11/2014
Description: 

Presentation at the 2014 Active Living Research Annual Conference.

An animated version of this presentation can be viewed here.

Abstract: 

Background and Purpose
Environmental effects on child health, including obesity, are well established. Studies examining associations between schools and child health largely have focused on the immediate school environment (e.g., cafeteria, schoolyard). Accordingly, Harrison and Jones, call for conceptualizing school environments more broadly. In particular, they propose a multi-tiered model that includes the infrastructure of schools themselves, but also surrounding neighborhoods, since even children not residing in those areas nonetheless regularly traverse them.  Most importantly, if the areas surrounding schools have significant influence on student health, they may represent anchors around which to more efficiently deploy resources for environmental improvements. Additionally, inconclusive findings from previous studies, most examining food environments, warrant additional study of school neighborhoods.

With a large sample (n=12,118) of racial/ethnically diverse elementary school children, this study used hierarchical linear modeling to estimate the associations between objective assessments of low-income urban school neighborhoods and measured BMI expressed as BMI percentile. Of critical importance, this study accounted for individual-level factors such as race, gender, and age, to more robustly estimate the effects of park or fast-food density, population change, and other community-level health indicators.

Objectives
To examine associations between environmental aspects of neighborhoods surrounding schools and childhood body mass index percentile (BMIp) using a sophisticated hierarchical design to improve the validity of the results.

Methods
Health data were collected from elementary students as part of a non-profit program offering health screenings, education, and referrals.  Data at the community/neighborhood level was collected from various databases including the U.S. Census and the Walkscore website.  The student data used in this analysis was collected in the 2008-2009 academic year and contained 46 different schools falling in 25 unique zip codes. The distribution across grade levels was relatively even, ranging from 2,123 students in the kindergarten cohort (17.5%) to 1,894 in the fifth grade cohort (15.6%).  The schools were heavily minority (41.76% black, 33.28% Hispanic, 21.89% white, and 3.07% other), with 49.07% female and 50.93% male.

Our data have a two-level hierarchical structure where individuals are nested within school/neighborhood. Specifying the model in this way is important because ignoring the clustering effect can lead to false positives in hypothesis testing, something that calls into question some previous work in this area. We used HLM, which takes into consideration the intraclass correlation between individuals within the same cluster and adjusts for its effect accordingly. Therefore, it produces more appropriate significance tests while simultaneously examining the effects of variables at both individual and group levels.

Results
While race, age, and sex remained predictive, the presence of parks and fitness facilities were associated with additional reductions in BMI percentile.  Similarly, the number of fast food restaurants predicts higher BMI percentile, as do declining populations, which likely signal urban decay of some sort.  More complex relationships manifest among some other community-level variables in the models.  While many call for increased access to grocery stores, particularly in efforts to assist “food deserts,” our analysis shows that access does not necessarily promote health, at least among children.  That is, the positive relationship between grocery stores and BMI percentile among children illustrates the need for changing not only access to them, but also likely the types of foods they offer and ultimately the food choices of the consumers who use them. The latter would presumably focus on parents. Similarly, convenience stores often are regarded as having a preponderance of unhealthy food choices.  That they manifest in our analysis as health promoting likely has less to do with the convenience stores themselves, and more to do with the density of retail and shopping in areas, which have been show to promote physical activity (mainly walking) resources. This is additionally evidenced by the effect of population size itself, where higher population densities may correspond to greater numbers of destinations within neighborhoods.

Differential estimates of BMI percentile among children based on the results of Model 2 are particularly illuminating.  Using the values from our data, the predicted BMI percentile at age 10 by race/ethnicity and sex shows a 15- point drop in BMI percentile for “obesogenic” vs. “non-obesogenic” neighborhoods.

Conclusions
This paper demonstrates that aspects of the environment in the neighborhoods surrounding schools indeed are associated with childhood BMI percentile, pointing to the fact that they should be regarded as significant zones of health influence for children.

Implications for Practice and Policy
Where redevelopment efforts have previously focused on classically defined neighborhood boundaries, our study suggests that neighborhood redevelopment efforts by HUD and other non-profits (e.g. Local Initiative Support Corporation) should consider targeting the radial areas around schools, rather than traditionally defined neighborhoods.  This is particularly important because improved child health manifests healthier adults later on.  While traditional neighborhood boundaries will capture a cross-section of the public, the number of children affected by improvements to school neighborhoods ultimately may pay greater health dividends, and the full range of corollary benefits, as they age.

References

  1. Ball K, Timperio A, Crawford D. Understanding environmental influences on nutrition and physical activity behaviors: where should we look and what should we count? Int J Beh Nutri Phy Act. 2006;3:33.
  2. Dunton GF, Kaplan J, Wolch J, Jerrett M, Reynolds KD. Physical environmental correlates of childhood obesity: a systematic review. Obes Rev. 2009;10:393-402.
  3. Rahman T, Cushing RA, Jackson RJ. Contributions of built environment to childhood obesity. Mt Sinai J Med. 2011;78:49-57.
  4. Burdette HL & Whitaker RC. Neighborhood play-grounds, fast food restaurants, and crime: relationships to overweight in low-income preschool children. Prev Med. 2004;38:57-63.
  5. Kipke M, Iverson E, Moore D, et al. Food and Park Environments: Neighborhood-level Risks for Childhood Obesity in East Lost Angeles. J Adol Health. 2007;40:325-333.
  6. Feng J, Glass TA, Curriero FC, Stewart WF, Schwartz, BS. The built environment and obesity: a systematic review of the epidemiologic evidence. Health and Place. 2010;16:175-190.
  7. Ding D, Sallis J, Kerr J, Lee S, Rosenberg D. Neighboorhood Environment & Physical Activity Among Youth. Am J Prev Med. 2011;41:422-455.
  8. Jones NR, Jones A, van Sluijs EMF, Panter J, Harrison F, Griffin SJ. School environments and physical activity: the development and testing of an audit tool. Health and Place. 2010;16:776–783.
  9. Harrison F, Jones AP. A framework for understanding school based physical environmental influences on childhood obesity. Health Place. 2012;18:639-48.
  10. Austin SB, Melly SJ, Sanchez BN, Patel A, Buka S, Gortmaker SL. Clustering of fast-food restaurants around schools: a novel application of spatial statistics to the study of food environments. Am J Public Health. 2005;95:1575-1581.
  11. Zenk SN, Powell LM. United States secondary schools and food outlets. Health and Place. 2008;14:336-346.
  12. Seliske LM, Pickett W, Boyce WF, Janssen I. Association between the food retail environment surrounding schools and overweight in Canadian youth. Pub Health Nutr. 2009;12:1384–1391.
Authors: 
Jason Wasserman, PhD, Richard Suminski, MPH, PhD, Juan Xi, PhD, Carlene Mayfield, MPH, Alan Glaros, PhD, & Richard Magie, DO
Location by State: 
Study Type: 

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