Andrew Springer, DrPHAssistant Professor, University of Texas SPH-AustinMichael & Susan Dell Center for Advancement of Healthy LivingBuilding Bridges Conference- TDSHS, June 16, 2010

Ecological perspectives for PA

School-based health promotion strategies for PA

Examples of partnerships to promote PA in children

Trends in U.S. Child Obesity*Obesity is > 95th Percentile for BMI by Age/Sex

Sources: Ogden et al., 2006; Hoelscher et al, SPAN 2004-05 study; CATCH ‘07.

HP 2010Goal

“If there were a single medication you could take – a pill that is free, with no side effects – that helped reduce your risk of developing or dying from many chronicdiseases, would you take it?

Daily physical activity is that magic pill.”-Jane Wargo & Russell Pate

Chronic disease prevention• Hypertension, type 2

diabetes, obesity, CVD.• Improves overall health

and adult health status

Cardiovascular system

Musculoskeletal system

Mental health, psychological and emotional well-being• Reduces stress &

symptoms of depression and anxiety

• Improves self-esteem

IOM, 2005

1 hour or more of PA every day.

Most of the 1 hour should be MPA or VPA

Vigorous intensity activity on at least 3 days per week.

Muscle-strengthening and bone-strengthening activity on at least 3 days/ week.

(USDHHS 2008)

Healthy People (HP) 2010: 50% MVPA in PE• 39.1% MVPA in PE (3rd, 4th, 5th graders).

HP 2010 Goal: 85% of children (adolescents)engage in VPA on 3 or more days/wk.• 67% of girls & 74% of boys (n= 1381 4th

graders).

American Academy of Pediatrics: 1-2 hrs/day• 43% of girls & 65% of boys spent ≥3 hrs

watching TV/playing video games (4th grade).

Hoelscher, Springer et al, 2010

How do we increase physical activity in children and

adolescents?

The LaLonde Report (1974): “The Genesis of Health Promotion”

First report from industrialized nation: health is not determined only by biological factors.

Recognition that biomedical interventions are not the main cause of well-being of a population.

“Field of Health” influenced by 4 aspects: Human biology Environment Health services Lifestyles

Sallis & Owen, 1997

The Ottawa Charter for Health Promotion(1986): 1st Int’l conf. on health promotion.• Importance of socio-cultural and economic

influences of health.• 5 areas of action: Re-orienting health services toward prevention Building healthy public policy Creating supportive environments Strengthening community action Developing personal skills

Ecological Fallacy: inferences about the nature of individuals are based solely upon aggregate statistics for the group to which those individuals belong.

Example: Florida sells the most cat food and has the most senior citizens = senior citizens eat cat food.

Yum!

Reductionist Fallacy: incorrect conclusions about group-level processes are based on individual-level data.

•Example: Race causes violence because higher arrests for violent crime among African Americans.

•40% of poor Blacks live in areas of extreme poverty vs. 7% of poor whites. (Wilson, 1987)

Racial/Ethnic disparities in physical activity.

Cross-sectional analysis of 17,007 teens in the Nat’l Longitudinal Study of Adolescent Health.

Findings: Participants attended segregated schools: • 80% of Hispanic students attended schools with student

populations that were majority white (66%)

• Nearly 40% of the white adolescents attended schools that were >94% white.

• Black/Hispanic students attended poorer schools

Black and Hispanic adolescent girls reported lower PA than white girls.

Black and Hispanic adolescent girls were more likely to attend poorer schools with lower levels of physical activity

No difference within schools between

black, white, and Hispanic girls’ PA levels.

Within the same schools, black and Hispanic boys had >PA when compared to white boys.

Lower physical activity levels in Hispanic and black girls largely attributable to the schools they attended.

Black and Hispanic males had higher activity levels than white males when attending the same schools.

Future research is needed to determine the mechanisms through which school environments contribute to racial/ethnic disparities in adolescent physical activity

Objective: To compare PA participation in children by parental language and ethnicity: (Spanish-Hispanic, English-Hispanic, and English Other).

Methods: Cross-sectional analysis of SPAN 2004-05

data (n = 22,049 4th, 8th, 11th graders)

Springer, Barroso , et al., J Immigrant Minority Health 2010

Span (ref) 1.00 1.00 1.00

Eng-Hisp 1.52 (1.23, 1.88)

1.67 (1.36, 2.04)

1.71 (1.40, 2.10)

Eng-Other 1.46 (1.18, 1.80)

2.58(2.10, 3.17)

2.06 (1.68, 2.51)

%

20

30

40

50

60

70

80

4th Graders 8th Graders 11th Graders

Spanish-Hisp

English-Hisp

English-Other

• Acculturation Hypothesis: Culture = Lifestyle• Representative study of 5,406 ninth-grade students in public schools

in Matamoros (Mexico) and Lower Rio Grande Valley (Texas, U.S.) found similar participation in sports (Perez et al., ‘06).

• Familismo: putting family needs before one’s own; Hispanic girls more likely to report child care (Grieser et al., 2006).

• Communication & Social Barrier: Is language a barrier for accessing organized PA? • More English-speaking parents reported receiving communication

from school (NHES, 2003)

• Discrimination & Exclusion: Is language a target for discrimination by dominant ethnic groups? • Non-English adolescents at >risk of alienation (Yu et al., 2003)• Lower volunteer opportunities for Sp-speaking parents (NHES, 2003)

• Language as Proxy for Economic Status(SES)

Definitions Ecology: the interrelationship between

organisms and their environment. Environment: space external to

individuals

Ecological perspective: emphasizes the interaction between people and their physical and socio-cultural surroundings.(the key to ecological models).

Sallis et al., 2006; Sallis & Owen, 1997

•Multiple dimensions & levels of influence

•Emphasis on place: behavior-specific models.

•Environments directly influence behaviors.

•Interactions of influence across dimensions.

Policy

Sallis et al., 2006

Policy

Policy

Natural/BuiltEnvironment

Inform.

SocialCulture

Sallis et al., 2006

Policy

Sallis et al., 2006

Behavior Settings

Perceptions

Neighborhood

Home

Work place

RecreationEnvironment

School

Behavior-Specific Models & Settings

Policy

Sallis et al., 2006

Policy

Sallis et al., 2006

Policy

Sallis et al., 2006

Policy

Sallis et al., 2006

Policy

Sallis et al., 2006

Interactions of Influence across Interactions of Influence across DimensionsDimensions

Study Objective: To assess the association of parental TV rules (policy environment) on children’s meeting AAP guidelines of ≤2 hours TV watching/day

•Examine potential modifying effect of TV in bedroom (built environ.), parent TV watching, Afterschool context (social environments)

Sample: n = 734 primarily Hispanic 4th graders

Methods: Self-administered questionnaire

AOR: 1.68 (1.22, 2.32)

Adjusted for age, gender, ethnicity, parent language

AOR: 1.04 (.50, 2.19) 2.03 (1.39, 2.97)

AOR: 1.80 (1.26, 2.56) 0.71 (0.30, 1.69)

Policy Environment: Children with Parental TV Limits more likely to meet AAP recommendations

Social Environment: Children with high TV watchingparents less likely to meet AAP recommendations.

Interactions of Influence across Dimensions:•TV location modifies TV rule and AAP•Nonsignificant association when parents watch TV frequently

“… have more influence on the lives of young people than any other social institution except the family and provide a setting in which friendship networks develop, socialization occurs, and norms that govern behavior are developed and reinforced.” -Healthy People 2010

Students who participated in school PA did not experience negative effects on their standardized test scores, though less time was available for other academic subjects.

Sallis et al, 1999Shephard, 1996Dwyer et al, 1983

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6

No. Fitness Standards Achieved

SA

T 9

Per

cen

tile

Reading MathCA Dept. of Education, 2002

Self-report: diary, questionnaires, activity checklists (SAPAC)

Direct observation (SOFIT, SOPLAY)

Pedometers, accelerometers, heart rate monitors.

Intrapersonal• Classroom PA Curriculum

Policy/Social Environment• Mandated PA time• PE Organization/Training (CATCH)• Activity Breaks• Built Environment• Community-School Partnership

• Salmon et al. (2007): Review of PA studies. •5 intervention curriculum-only studies : 1 effective but not effective in replication.

•TV curriculum (e.g., Planet Health) = effects on reducing TV/ weight gain.

Policy/Social Environment Mandated PA Time PE Organization/Training (CATCH) Activity Breaks Built Environment Community-School Partnership

CDC YRBS

Texas Senate Bill 19 (2001): K – 5th grade The Texas Coalition for Coordinated School

Health and Physical Education

•30 minutes of daily structured physical activity or a total of 135 minutes/week

•Coordinated School Health Program (CSH)

•Classroom curriculum, physical activity, child nutrition services, and parental involvement.

•Creation of local district School Health Education Advisory Council.

Kelder SH, Springer AE, Barroso C, Smith C, Sanchez E, Hoelscher DM, Ranjit N.

RESEARCH AIMS1)To assess awareness of and adherence to

SB19 in a representative sample of Texas elementary schools.

2)To assess the implementation of SB19 in Texas/Mexico border schools (2 regions): • weekly minutes of PA; • quality of child PA during PE.

135 min per week

R10-R11 = 82 min/week

(Kelder , Springer et al., J Public Health Policy, 2009)

Figure 2. Direct Observation of PE Class (SOFIT; n = 19 schools)

0

10

20

30

40

50

60

70

3rd Grade 4th grade 5th Grade Total

% M

VPA

Region 10 Region 11

p=.033 p=.18 p=.40

MVPA = % of PE class time where students are engaged in movement to vigorous physical activity

HP 2010 objective

p = .029

California Legislation: 50% of PE classes to be spent in MVPA by 2013.

Increase supervision of recess (Sallis et al., 2001;

Sallis et al., 2003; Farley et al., 2007)•CATCH Middle School: Open Gym

Provide PA as a reward, not discipline (PLAY-ON study, Leatherdale et al., 2010).

WOW Time: 30 minutes of PA/day (Springer et al., in progress)

Policy/Social Organization Mandated PA Time PE Organization/Training (CATCH) Activity Breaks Built Environment Community-School Partnership

• Students participate in MVPA for >=50% of class time.

Healthy People 2010: PE Objective

• Maintain children in high levels of activity.

• All children participate.

• Non-competitive, funactivities.

Steps to a Healthier Houston-Harris County Consortium (Steps Consortium) • Formed in 2003; 25 area organizations• The Houston Endowment Inc. awarded $2.4

million to implement CATCH in >450 schools

Travis County CATCH Project• UTSPH & 4 central Texas districts• Funding from Michael & Susan Dell Foundation for

implementation in ~100 elementary schools• CATCH Consortium & support of CATCH teams

05

101520253035404550

Baseline (Spring/Fall '06)Time 2 (Spring '07) Time 3 (Fall '07)

% MVPA

Percentage of PE Class Time 3rd, 4th, & 5th grade students engaged in MVPA. Harris

County CATCH (n = 94 class observations/ 36 schools).

*p<.001

36.7%41.6%

46.3%

*

*

(Hoelscher, Springer et al., in process)

Percentage of PE class time 3rd, 4th, and 5th grade students engaged in MVPA.

Travis County CATCH Project. (n = 103 class observations).

a, b

b, c

[a: p = .023; b: p = <.001; c: p = .001.]

HP 2010Goal

38.842.8

48.4

Hoelscher, Springer, et al., Obesity 2010

Policy/Social Environment Mandated PA Time PE Organization/Training (CATCH) Activity Breaks Built Environment Community-School Partnership

• “Promoting Lifetime Activity in Youth” (PLAY) (Pangrazi et al., 2003; Ernst et al., 1999)

• Teacher-led games. (Connolly & McKenzie, 1995)

• “Take 10!” (Stewart et al, 2004)

**

*

Murray (UTSPH), unpublished

At Risk: adaptability, social skills, leadership, study skills, functional communication

To assess the effect of low-cost strategies for promoting children’s MVPA during recess and WOW time.

Strategies:• Peer-led Games Approach• Teacher-led Approach• Playground Markings

Design: RCT in 8 schools

Policy/Social Environment Mandated PA Time PE Organization/Training (CATCH) Activity Breaks Built Environment Community-School Partnerships

“We shape our buildings, and thereafter they shape us.”

-Winston Churchill

(1874-1965)

.

Boston Globe, 2005

=

Stratton (2000): Children 5-7 yrs (UK). MVPA increased by 18 mins/d.

Stratton & Mullan (2005): 4-11 yrs: MVPA increased from 37% to 50%.

Ridgers et al. (2007)

Games equipment & activity cards intervention increased MVPA in 5th/6th grade girls in Belgian. (Verstraete et al, 2006).

Middle school students attending schools with improved playgrounds had higher observed MVPA (Sallis et al., 2001).

Policy/Social Environment Mandated PA Time PE Organization/Training (CATCH) Activity Breaks Built Environment Community-School Partnerships

• Schools and communities have long been cited as important vehicles for promoting PA in young people (IOM, 2006; USDHHS, 1996)

• Partnerships among schools, community organizations and businesses: recommended to implement PA programs (CDC, 1997).

• PLAY-ON study (n = 30 schools; 2,379 5-8 graders): children more likely to be moderately active if attending a school with well-established community partnerships (Leatherdale et al., 2010)

Marathon Kids•Established 1996 in Austin, Texas.

•Currently operating in 7 sites in the U.S.

Objectives:•To engage children (and families) in running/walking 26.2 miles over six month period. •To promote children’s consumption of fruit & vegetables 5 times a day/26 days per month.

Fuel & Mileage Logs

School physical activity legislative mandates (Senate Bill 19/530)

Structured School Time for PA• Before, during & after school.

Bumper Stickers Marathon Kids T-Shirts Information Packets Presentations Media Coverage

Teachers Parents Volunteers/Comm.

Leaders; Businesses

Teachers/Schools: Enroll students in

program. Track progress with

miles. Facilitate

transportation to celebratory events.

Austin MayorWill Wynn(Keepin’ AustinWeird…)

LA MayorAntonio Villaraigosa

Shawn ColvinMusician

EduardoSanchezTexasHealthCommis.

Public Recognition = “Kick-Off” and “Final Mile Run Events”

Final Mile Medal & Finisher T-Shirt

Springer, Kelder, Ranjit et al, under review

Beware the ecological fallacy… but also beware of a reductionist fallacy• The sociological imagination: the capacity

to discern the relationship between large-scale social forces and the actions of individuals.

Ecological Models: a broad framework for exploring social-environmental influences on PA• Too broad? Need to continue to elucidate

dimensions of ecological models Schools as a key setting for PA

How do we enhance social environment/social organization of schools to promote child PA? (e.g., Wellness committees)

How do we harness school-community partnerships to increase effectiveness of school policies and quality of PA?

How do we expand the focus from individuals to settings (‘active schools’, ‘active school districts’, and active communities)?