Research
Original Investigation
Promoting Physical Activity With the Out of School Nutrition and Physical Activity (OSNAP) Initiative A Cluster-Randomized Controlled Trial Angie L. Cradock, ScD; Jessica L. Barrett, MPH; Catherine M. Giles, MPH; Rebekka M. Lee, ScD; Erica L. Kenney, ScD; Madeleine E. deBlois, MSEd, ScD; Julie C. Thayer, MS, MPH; Steven L. Gortmaker, PhD
IMPORTANCE Millions of children attend after-school programs in the United States.
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Increasing physical activity levels of program participants could have a broad effect on children’s health. OBJECTIVE To test the effectiveness of the Out of School Nutrition and Physical Activity (OSNAP) Initiative in increasing children’s physical activity levels in existing after-school programs. DESIGN, SETTING, AND PARTICIPANTS Cluster-randomized controlled trial with matched program pairs. Baseline data were collected September 27 through November 12, 2010, with follow-up data collected April 25 through May 27, 2011. The dates of our analysis were March 11, 2014, through August 18, 2015. The setting was 20 after-school programs in Boston, Massachusetts. All children 5 to 12 years old in participating programs were eligible for study inclusion. INTERVENTIONS Ten programs participated in a series of three 3-hour learning collaborative
workshops, with additional optional opportunities for training and technical assistance. MAIN OUTCOMES AND MEASURES Change in number of minutes and bouts of moderate to vigorous physical activity, vigorous physical activity, and sedentary activity and change in total accelerometer counts between baseline and follow-up. RESULTS Participants with complete data were 402 racially/ethnically diverse children, with a mean age of 7.7 years. Change in the duration of physical activity opportunities offered to children during program time did not differ between conditions (−1.2 minutes; 95% CI, −14.2 to 12.4 minutes; P = .87). Change in moderate to vigorous physical activity minutes accumulated by children during program time did not differ significantly by intervention status (−1.0; 95% CI, −3.3 to 1.3; P = .40). Total minutes per day of vigorous physical activity (3.2; 95% CI, 1.8-4.7; P < .001), vigorous physical activity minutes in bouts (4.1; 95% CI, 2.7-5.6; P < .001), and total accelerometer counts per day (16 894; 95% CI, 5101-28 686; P = .01) increased significantly during program time among intervention participants compared with control participants. CONCLUSIONS AND RELEVANCE Although programs participating in the OSNAP Initiative did not allot significantly more time for physical activity, they successfully made existing time more vigorously active for children receiving the intervention. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01396473
JAMA Pediatr. 2016;170(2):155-162. doi:10.1001/jamapediatrics.2015.3406 Published online December 7, 2015.
Author Affiliations: Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts (Cradock, Barrett, Giles, Lee, Kenney, deBlois, Thayer, Gortmaker); currently with the Frances McClelland Institute for Children, Youth, and Families, The University of Arizona, Tucson (deBlois). Corresponding Author: Angie L. Cradock, ScD, Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02215 ([email protected]).
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Research Original Investigation
Promoting Physical Activity With the OSNAP Initiative
P
articipation in daily physical activity is associated with better cardiovascular and metabolic disease risk profiles and improved mental and physical health among children and youth.1 However, most children and adolescents do not meet nationally recommended levels of physical activity.2 While evidence indicates that interventions can promote physical activity during the school day,3 limited conclusive research has been performed to determine how best to increase physical activity in the hours after school.4-6 Several randomized clinical trials have examined the effect of creating new physical activity–focused after-school programs on physical activity and weight status outcomes.4-7 An alternate approach, the one used in this study, focuses on implementing physical activity–promoting strategies in existing afterschool programs.8 More than 10 million children in the United States participate in after-school programs for a mean of 7.4 hours per week, with children of color and low-income children participating at higher rates.9 This time represents an important opportunity to engage participants in the physical activity necessary to meet the national recommendations by adding time into the program schedule for physical activity or by making available time more physically active. Prior randomized clinical trials in existing programs have provided single-sport or singleactivity curriculum and intervention materials and training for existing staff to implement interventions10-12 or added additional activity-specific programming.13 Such strategies may not be feasible if resources and flexibility in programming schedules are limited. More flexible strategies to increase physical activity offerings through staff training show promise for improving physical activity levels among existing after-school program participants. 12,14 Such strategies using existing resources may cost less and may have broader appeal than interventions focused on single sports. In this clusterrandomized controlled trial, we tested whether an organizational change, collaborative learning approach can be implemented in various school and community–based after-school programs.
At a Glance • This cluster-randomized controlled trial examined the effectiveness of the Out of School Nutrition and Physical Activity (OSNAP) Initiative in increasing children’s physical activity levels in 20 existing after-school programs. • There was no effect of the intervention on moderate to vigorous physical activity, but after-school programs participating in the OSNAP Initiative were successful in making existing program time more vigorously active for children. • Compared with control participants, vigorous physical activity levels among intervention participants increased by 36.0%.
ously from mid-October through the end of May. Before randomization, programs were matched on key characteristics obtained from administrative records, including the afterschool program provider, snack provider, physical activity facilities, and school-level racial/ethnic and socioeconomic composition. The study manager (C.M.G.) matched and enrolled programs. After baseline data collection, the programs within each matched pair were randomized to intervention or control (ie, delayed intervention) status by a masked external statistician using a computer-based random number generator. Neither program directors nor study authors were masked to randomization status, whereas data collectors were masked. After-school programs randomized to the control condition were invited to participate in the intervention the following school year (2011-2012). The study was approved by the Harvard T. H. Chan School of Public Health Institutional Review Board and the Boston Public Schools Office of Data and Accountability. Informed consent was obtained for all study participants. Before baseline data collection, researchers (J.L.B., C.M.G., R.M.L., E.L.K., M.E.deB., and J.C.T.) visited the 20 programs at child dropoff or pickup times to distribute active consent letters available in several languages. Parents or guardians gave written permission for children’s participation, and each child provided verbal assent. The full study protocol can be found in Supplement 1.
Intervention
Methods Design and Sample This experimental study was a cluster-randomized controlled trial conducted in 20 after-school programs (10 intervention sites paired with 10 matched control sites) in Boston, Massachusetts, from the fall of 2010 through the spring of 2011. The Figure shows the flow of programs and individual participants in the study. The study investigated changes in physical activity from baseline (September 27 through November 12, 2010) to follow-up (April 25 through May 27, 2011) among children in intervention programs compared with control programs. Eligible after-school programs were identified and recruited to participate in the study through collaboration between study staff (C.M.G.) and local community program providers (eg, Boys & Girls Clubs, the YMCA, and Boston Public Schools). Programs were eligible if they served children 5 to 12 years old, enrolled at least 40 children, and ran continu156
The Out of School Nutrition and Physical Activity (OSNAP) Initiative15,16 works with after-school programs to improve nutrition and physical activity–related practices, environments, and policies using a socioecological model17 and a communitybased participatory research approach.18 The OSNAP Initiative resources and links to research evidence are available online (http://www.osnap.org). The 2 physical activity goals were (1) to include 30 minutes of moderate, fun physical activity for every child every day (including outdoor activity, if possible) and (2) to offer 20 minutes of vigorous physical activity (VPA) 3 times per week. Over a 6-month intervention period, teams from intervention sites (including program directors and staff) were invited to participate in a series of three 3-hour OSNAP Initiative learning collaborative (LC) sessions modeled after existing community partner professional development programs and prior research. 19,20 At LC sessions, teams reviewed reports of physical activity time provided and participation rates at baseline in their programs compared with the
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Original Investigation Research
Figure. Consolidated Standards of Reporting Trials Diagram of the Flow of Individual Participants Through the Study 222 Programs assessed for eligibility 202 Programs excluded 191 Did not meet inclusion criteria 115 Program duration 47 Enrollment size 16 Age of students 13 Other 4 Declined to participate 7 Did not respond
20 Programs randomized (prior to randomization, programs were matched on program partner, snack provider, school-level student demographics, and physical activity facilities)
10 Programs received the intervention (563 students)
10 Programs served as control (580 students)
288 Students consented to participate
308 Students consented to participate
37 Students were excluded 15 Not present during data collection 0 Refused 16 Meter lost or malfunctioned 6 Insufficient valid wear 251 Students had valid baseline outcome data
40 Students were excluded 15 Not present during data collection 3 Refused 12 Meter lost or malfunctioned 10 Insufficient valid wear 268 Students had valid baseline outcome data
69 Students were excluded 40 Not present or left program 1 Refused 7 Meter lost or malfunctioned 21 Insufficient valid wear 182 Students had valid longitudinal outcome data
48 Students were excluded 27 Not present or left program 1 Refused 1 Meter lost or malfunctioned 19 Insufficient valid wear 220 Students had valid longitudinal outcome data
The primary outcome was physical activity measured via accelerometer.
OSNAP Initiative goals. Using tools provided by study staff, after-school teams identified areas for improvement and set action plans to improve program practices, develop relevant policies, and communicate changes to parents and other partners. At LC sessions, program staff members shared progress with other teams and participated in skill development sessions. Program staff members were also offered additional physical activity skill-building sessions. These additional sessions focused on strategies to incorporate physical activity breaks and small-space activities into the program, including training on the Food & Fun After School curriculum,21 recess-focused training by Playworks,22 and SPARK23 training. Between LC sessions, study staff provided intervention programs, with technical assistance and reminders via telephone, newsletter, and email. Sites were invited to apply for up to $200 to support implementation.
Data Collection Data collectors visited each program for 1 week (5 weekdays) at baseline and follow-up to distribute and collect jamapediatrics.com
accelerometers and to observe program activities, including types and amount of physical activity provided. Data collectors recorded the start and end times of activities offered in several predetermined categories, including free active play (ie, free choice of activity) and structured active play (ie, physical activity led by program staff), and indicated how many and what grade levels of children attended each activity and whether the activity was located indoors or outdoors. Child demographic information, including sex, race/ ethnicity, grade, and age, were collected via parent report on consent forms. From the National Oceanic and Atmospheric Association, study staff obtained local weather data on hourly precipitation and temperature for each day of data collection24 and the 30-year mean annual temperature.25 The average daily temperature during data collection periods, percentage deviation from the average annual temperature, and presence of precipitation (yes or no) were documented for each afterschool period between 2 and 6 PM to account for daily weather changes. (Reprinted) JAMA Pediatrics February 2016 Volume 170, Number 2
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Promoting Physical Activity With the OSNAP Initiative
Outcome Measures
Statistical Analysis
Child-Level Outcomes Baseline (September to November 2010) and follow-up (April to May 2011) data were collected on the primary outcome measure of the number of minutes of moderate to vigorous physical activity (MVPA) that individual children accumulated overall during the after-school period. Secondary outcomes included (1) VPA minutes and sedentary activity minutes accumulated overall; (2) the number of MVPA, VPA, and sedentary activity minutes accumulated in modified 10-minute bouts (periods of continuous activity intensity, allowing for 2 minutes to fall below intensity threshold)2; and (3) total accelerometer counts during the after-school period. Students wore accelerometers (GT3X/GT1M or MTI/CSA 7164; Actigraph) on their hip on a fitted belt continuously during the after-school period for 5 school days (Monday through Friday) at baseline and at follow-up. Functionality of monitors was verified for each available accelerometer before assignment for research use. Accelerometer counts were collected in 1-minute epochs, and the number of minutes spent in MVPA were estimated with age-specific cut points for children 6 to 18 years old26 used in national surveillance,2 with thresholds of 4 metabolic equivalent counts for MVPA and 6 metabolic equivalent counts for VPA. Less than 100 accelerometer counts per minute was considered sedentary activity. These cut points based on 1-minute epochs demonstrate excellent accuracy in classifying activity levels among children.27 Nonwear periods were defined according to established protocols as 60 consecutive minutes of zero accelerometer counts, allowing for up to 2 minutes below 100 accelerometer counts.28 Implausibly high values (>20 000 counts) were replaced with imputed counts based on the mean of the last and next valid minutes (when ≤10 in succession) or were set to missing (when >10 in succession). Valid minutes were restricted to minutes during the defined after-school period for which data collectors documented students wearing accelerometers, and valid days consisted of at least 1 hour of data collected during program time. Students with 2 or more valid days at both baseline and follow-up were included in the final analysis to be consistent with criteria used in school-based evaluations29 and to ensure nondifferential attrition in the sample by program. Estimates were also calculated using data from all participants, and these results were not appreciably different (eTables 1, 2, and 3 in Supplement 2).
Linear mixed-effects models were used to investigate whether students at participating OSNAP Initiative programs experienced greater increases in accelerometer-derived physical activity levels during the program period compared with those at control programs. The intervention effect was estimated by an interaction term of period (follow-up is 1, and baseline is 0) by intervention (intervention is 1, and control is 0), in addition to period and intervention status main effects. Models were adjusted at the child level for daily minutes monitored; child sex, race/ethnicity, and grade; matched pair indicators at the program level; model of accelerometer worn (to account for potential differences in output between models30,31); and percentage deviation from the average annual temperature and the presence of precipitation at the observation day level. Program-level random intercepts were used to account for the correlation due to clustering of students within programs. A compound symmetry within-person error covariance structure was used to account for nesting of successive daily observations within students.32 The df for significance tests was calculated using the between-within method.33,34 Adjusted means for each outcome at baseline and follow-up were estimated from models adjusting for clustering, monitored minutes, and monitor model only. Post hoc analyses using stratified mixed models examined whether intervention effects differed by sex or grade (kindergarten through 2 vs 3-6). Analyses were performed between March 2014 and August 2015 using statistical software (SAS, version 9.3; SAS Institute Inc). Sample-size calculations completed before this study were based on observed data from children in after-school programs. They suggested that, with 30 participants clustered within 10 matched intervention and control programs, assuming an intraclass correlation of children’s physical activity minutes within programs of 0.01 and a correlation of 0.6 between baseline and follow-up physical activity minutes, researchers would have 80% power to detect a mean (SD) difference of 4.6 (19.7) minutes of MVPA as a primary outcome. Standard deviations were based on data collected in 4 pilot sites.
Program-Level Outcomes The mean daily minutes offered to the typical child for each type of activity were calculated by summing the number of minutes recorded by data collectors in the daily log, weighted by the proportion of children present at the program who were attending the particular activity. Researchers calculated the number of days on which programs provided at least 30 minutes of physical activity time to all attendees. The mean program-level physical activity minutes offered per day were calculated for baseline and follow-up, and changes by condition were compared, accounting for clustering of days within programs. 158
Results OSNAP Initiative Exposure and Participation Staff from all intervention programs attended LC sessions 1 and 2, and 9 of 10 programs participated in LC session 3. All intervention programs included the goal of increasing physical activity in their action plans. Nine of 10 intervention programs included practice, policy, or communication actions for providing 30 daily minutes of physical activity time for every child (including outdoor activity, if possible) as part of their action plans, and 6 of 10 intervention programs reported completing all specified actions. Intervention program staff attended additional physical activity skill training, including SPARK (2 programs), Food & Fun After School (4 programs), and Playworks (7 programs). On monthly reports, 5 intervention programs and 1 control program reported ever using a Food & Fun After School physical activity lesson. One intervention pro-
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Promoting Physical Activity With the OSNAP Initiative
Original Investigation Research
Table 1. Demographics of Participants Attending After-School Programs in the OSNAP Initiative Cluster-Randomized Controlled Trial Participating Childrenb Consenting Children (n = 596)a
All (n = 402)
Intervention (n = 182)
Control (n = 220)
Male
303 (50.8)
196 (48.8)
85 (46.7)
111 (50.5)
Female
293 (49.2)
206 (51.2)
97 (53.3)
109 (49.5) 22 (10.0)
Variable Sex, No. (%)
Race/ethnicity, No. (%) White non-Hispanic
55 (9.2)
30 (7.5)
8 (4.4)
Black non-Hispanic
192 (32.2)
123 (30.6)
44 (24.2)
79 (35.9)
Hispanic/Latino
196 (32.9)
140 (34.8)
68 (37.4)
72 (32.7)
Asian
25 (4.2)
13 (3.2)
9 (4.9)
4 (1.8)
128 (21.5)
96 (23.9)
53 (29.1)
43 (19.5)
78 (13.1)
53 (13.2)
27 (14.8)
26 (11.8)
Abbreviation: OSNAP, Out of School Nutrition and Physical Activity.
1
94 (15.8)
69 (17.2)
27 (14.8)
42 (19.1)
a
2
119 (20.0)
84 (20.9)
32 (17.6)
52 (23.6)
3
103 (17.3)
71 (17.7)
33 (18.1)
38 (17.3)
Consenting children were children enrolled at 20 after-school programs and consenting to participate in the study.
4
105 (17.6)
68 (16.9)
29 (15.9)
39 (17.7)
b
5
83 (13.9)
46 (11.4)
25 (13.7)
21 (9.5)
6
14 (2.3)
11 (2.7)
9 (4.9)
2 (0.9)
7.9 (1.8)
7.6 (1.6)
Participating children were all children at 20 after-school programs who provided at least 2 weekdays of valid accelerometer data per data collection period.
Other or unknown Grade, No. (%) Kindergarten
Age, mean (SD), y
7.8 (1.8)
7.7 (1.7)
gram used 4 Food & Fun After School activities. Five of 10 intervention programs applied for and received $200 to support implementation of their physical activity action planning goals.
Participants Twenty programs agreed to participate and be randomized to intervention or control (ie, delayed intervention) status. Approximately half of the program participants assented to participate in both intervention (51.2% [288 of 563]) and control (53.1% [308 of 580]) programs. Of the 251 students (87.2% [251 of 288]) in intervention programs and 268 students (87.0% [268 of 308]) in control programs with valid baseline accelerometer data, longitudinal analysis of change in accelerometerderived physical activity was conducted among 182 intervention participants (72.5% [182 of 251] retention) and 220 control participants (82.1% [220 of 268] retention). Participants were racially/ethnically diverse (Table 1). Approximately half were female (51.2% [206 of 402]), and students ranged from kindergarten through grade 6, with a mean age of 7.7 years. Children provided means of 4.2 days of physical activity data at baseline and 4.0 days at follow-up, with mean daily monitored times of 139.9 minutes at baseline and 142.5 minutes at follow-up (Table 2).
Program-Level Outcomes At baseline, intervention sites provided 30 or more minutes of physical activity on a mean (SD) of 2.3 (1.6) days compared with a mean (SD) of 3.2 (1.9) days provided by control sites (P = .27). Change in physical activity minutes offered to children during program time from baseline to follow-up was not significantly different between conditions (−1.2; 95% CI, −14.2 to 12.4; P = .87). Table 2 summarizes the types and locations jamapediatrics.com
of physical activity time provided by programs during observed days at baseline and follow-up.
Child-Level Outcomes Adjusting for the matched design and other variables, the intervention led to no significant change in MVPA minutes overall (P = .40) or in bouts of MVPA (P = .92) during program time (Table 3). However, participants in intervention programs increased VPA minutes per day (3.2; 95% CI, 1.8-4.7; P < .001) and VPA minutes per day in bouts (4.1; 95% CI, 2.7-5.6; P < .001) during program time relative to participants in control programs. No significant differences were observed in changes in total (P = .57) or modified bouts (P = .35) of sedentary activity time among intervention program participants compared with control participants. However, there were significant increases in total accelerometer counts per day (16 894; 95% CI, 5101-28 686; P = .005) among intervention participants compared with control participants. Subsequent stratified analyses by groupings of kindergarten through grade 2 and grades 3 through 6 suggested a differential intervention effect on overall MVPA and VPA. Among younger participants, the intervention was associated with an increase in MVPA minutes during program time (3.9; 95% CI, 0.5-7.2; P = .02) compared with controls, while it was associated with a decrease in MVPA minutes among older participants (−6.7; 95% CI, −9.9 to −3.6; P < .001). Among younger participants, the intervention was associated with an increase in VPA (4.8; 95% CI, 2.8-6.9; P < .001) compared with controls. Among older participants, the observed increase in VPA associated with the intervention was not statistically significant (1.5; 95% CI, −0.6 to 3.5; P = .17). Intervention effects did not differ significantly by participant sex. (Reprinted) JAMA Pediatrics February 2016 Volume 170, Number 2
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Promoting Physical Activity With the OSNAP Initiative
Table 2. Observed Characteristics of Participants Attending After-School Programs in the OSNAP Initiative Cluster-Randomized Controlled Trial Baseline (September to November 2010) Variable
All (n = 402)
Follow-up (April to May 2011)
Intervention (n = 182)
Control (n = 220)
179 (98.4)
219 (99.5)
All (n = 402)
Intervention (n = 182)
Control (n = 220)
Actigraph Accelerometer Model, No. (%) MTI/CSA 7164
398 (99.0)
0
0
0
GT1M
0
0
0
148 (36.8)
71 (39.0)
77 (35.0)
GT3X
4 (1.0)
3 (1.6)
1 (0.5)
254 (63.2)
111 (61.0)
143 (65.0)
Accelerometer Wear, mean (SD) Monitored time, d Daily monitored time, min
4.2 (1.0)
4.3 (0.9)
4.1 (1.0)
4.0 (1.0)
4.0 (1.0)
4.1 (1.0)
139.9 (33.4)
142.8 (33.9)
137.4 (32.7)
142.5 (33.2)
144.0 (35.4)
141.2 (31.3)
Physical Activity Time Offered per Day by Programs, mean (SD), min All physical activity
42.2 (19.6)
36.6 (18.4)
46.9 (19.4)
66.1 (20.6)
61.4 (23.3)
70.0 (17.1)
Outdoor physical activity
20.3 (23.0)
12.7 (11.8)
26.5 (27.7)
37.6 (22.0)
26.8 (16.6)
46.5 (22.1)
Indoor physical activity
22.0 (17.3)
23.9 (17.0)
20.4 (17.4)
28.6 (20.0)
34.6 (23.5)
23.6 (14.9)
Free play physical activity
25.8 (16.7)
21.7 (10.3)
29.2 (20.0)
45.2 (21.3)
41.5 (21.9)
48.4 (20.3)
Structured physical activity
16.4 (11.6)
15.0 (10.9)
17.7 (12.0)
20.9 (15.0)
19.9 (11.7)
21.7 (17.2)
Free indoor activity
11.4 (11.2)
13.5 (10.9)
9.7 (11.2)
15.9 (16.1)
20.0 (19.9)
12.4 (11.0)
Free outdoor activity
14.4 (19.0)
8.2 (9.1)
19.5 (23.1)
29.4 (21.0)
21.4 (14.0)
35.9 (23.5)
Structured indoor activity
10.5 (8.7)
10.4 (8.9)
10.6 (8.5)
12.7 (10.0)
14.6 (10.6)
11.1 (9.3)
5.9 (9.0)
4.6 (5.0)
8.2 (12.0)
5.4 (5.6)
10.5 (15.0)
By location
Free play or structured activitya
By location and structure
Structured outdoor activity
7.0 (11.2)
Weather, mean (SD) Average daily temperature, °F
58.4 (8.4)
57.0 (8.3)
59.5 (8.3)
61.2 (6.6)
61.2 (6.4)
61.2 (6.8)
% Deviation from the average annual temperature, °F
13.3 (16.3)
10.7 (16.2)
15.5 (16.1)
18.9 (12.9)
18.9 (12.5)
18.9 (13.2)
1.3 (0.9)
1.3 (0.9)
1.2 (1.0)
1.8 (1.0)
1.8 (0.9)
1.8 (1.0)
Precipitation, d
Abbreviation: OSNAP, Out of School Nutrition and Physical Activity. a
Free play identifies activity choices that are chosen by children while structured activity identifies opportunities during which program staff choose and lead activity for children.
Discussion Children in programs participating in the OSNAP Initiative increased VPA levels by 36.0%, or an estimated 3.2 minutes per day during the program period overall, and 4.1 minutes in bouts of VPA. Overall, the programs participating in the OSNAP Initiative did not make significant changes in time allotted for physical activity compared with controls but were successful in making existing time more vigorously active for children. Evidence among youth indicates that engaging in VPA may be associated with better fitness, academic achievement, and cognition and with lower adiposity and cardiovascular risk compared with engaging in moderate physical activity.1,35,36 While older students participating at OSNAP Initiative program sites did not increase MVPA, there was evidence that implementing the intervention was effective in increasing overall MVPA among younger program participants. Potentially, the technical assistance and tools and resources used were more applicable and appropriate to younger children. Activity patterns and preferences may change with age. Identification of program policies, practices, and communication strategies for engaging older students may be needed to achieve equitable results in these grades. 160
The observed relative increase in VPA per child (4.1 minutes) is similar to that in a meta-analysis5 of after-school program initiatives promoting physical activity and is consistent with changes seen in more recent studies of interventions adding specific programmed physical activities,37 using train-thetrainer approaches for soccer-focused activity promotion,10 and building programmatic capacity through staff skill development12 in existing program settings. The OSNAP Initiative provided technical assistance and training for existing program staff, with directed quality improvement goals that focused on improving the policies, practices, and communication strategies used in everyday program operation. The OSNAP Initiative was designed with a focus on policy and environmental changes that programs with varying existing resources could implement within existing structures to maximize sustainability. This approach was used successfully with both school-based and community-based programs. Nationally, approximately 57% of after-school participants attend school-based programs.9 This cluster-randomized controlled trial used a community-based approach that engaged after-school leaders and program providers in development and implementation. It also assessed changes in physical activity using objective assessment measures. Researchers used established accelerometer
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Promoting Physical Activity With the OSNAP Initiative
Original Investigation Research
Table 3. Effect of the OSNAP Initiative on Children’s After-School Physical Activity Levels Among Participants
Variable
Mean (SE)a
Mean
Baseline
Crude Changea
Follow-up
Intraclass Correlation Coefficienta,c
Adjusted Changeb Value (95% CI)
P Value
MVPA overall, min Intervention
23.8 (3.7)
32.5 (3.8)
8.7
0.13
Control
30.4 (3.7)
39.6 (3.8)
9.2
NA
−1.0 (−3.3 to 1.3) NA
.40 NA
MVPA in bouts, min Intervention
11.6 (4.1)
19.8 (4.2)
8.2
0.13
Control
18.9 (4.1)
26.7 (4.2)
7.7
NA
0.1 (−2.5 to 2.8) NA
.92 NA
VPA overall, min Intervention
8.9 (2.2)
12.1 (2.3)
3.2
13.7 (2.2)
13.5 (2.3)
−0.2
Intervention
3.1 (1.9)
4.6 (2.0)
1.5
Control
7.3 (1.9)
4.7 (2.0)
−2.6
Control
0.12
3.2 (1.8 to 4.7)
NA
NA
Original Investigation
Promoting Physical Activity With the Out of School Nutrition and Physical Activity (OSNAP) Initiative A Cluster-Randomized Controlled Trial Angie L. Cradock, ScD; Jessica L. Barrett, MPH; Catherine M. Giles, MPH; Rebekka M. Lee, ScD; Erica L. Kenney, ScD; Madeleine E. deBlois, MSEd, ScD; Julie C. Thayer, MS, MPH; Steven L. Gortmaker, PhD
IMPORTANCE Millions of children attend after-school programs in the United States.
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Increasing physical activity levels of program participants could have a broad effect on children’s health. OBJECTIVE To test the effectiveness of the Out of School Nutrition and Physical Activity (OSNAP) Initiative in increasing children’s physical activity levels in existing after-school programs. DESIGN, SETTING, AND PARTICIPANTS Cluster-randomized controlled trial with matched program pairs. Baseline data were collected September 27 through November 12, 2010, with follow-up data collected April 25 through May 27, 2011. The dates of our analysis were March 11, 2014, through August 18, 2015. The setting was 20 after-school programs in Boston, Massachusetts. All children 5 to 12 years old in participating programs were eligible for study inclusion. INTERVENTIONS Ten programs participated in a series of three 3-hour learning collaborative
workshops, with additional optional opportunities for training and technical assistance. MAIN OUTCOMES AND MEASURES Change in number of minutes and bouts of moderate to vigorous physical activity, vigorous physical activity, and sedentary activity and change in total accelerometer counts between baseline and follow-up. RESULTS Participants with complete data were 402 racially/ethnically diverse children, with a mean age of 7.7 years. Change in the duration of physical activity opportunities offered to children during program time did not differ between conditions (−1.2 minutes; 95% CI, −14.2 to 12.4 minutes; P = .87). Change in moderate to vigorous physical activity minutes accumulated by children during program time did not differ significantly by intervention status (−1.0; 95% CI, −3.3 to 1.3; P = .40). Total minutes per day of vigorous physical activity (3.2; 95% CI, 1.8-4.7; P < .001), vigorous physical activity minutes in bouts (4.1; 95% CI, 2.7-5.6; P < .001), and total accelerometer counts per day (16 894; 95% CI, 5101-28 686; P = .01) increased significantly during program time among intervention participants compared with control participants. CONCLUSIONS AND RELEVANCE Although programs participating in the OSNAP Initiative did not allot significantly more time for physical activity, they successfully made existing time more vigorously active for children receiving the intervention. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01396473
JAMA Pediatr. 2016;170(2):155-162. doi:10.1001/jamapediatrics.2015.3406 Published online December 7, 2015.
Author Affiliations: Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts (Cradock, Barrett, Giles, Lee, Kenney, deBlois, Thayer, Gortmaker); currently with the Frances McClelland Institute for Children, Youth, and Families, The University of Arizona, Tucson (deBlois). Corresponding Author: Angie L. Cradock, ScD, Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02215 ([email protected]).
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Research Original Investigation
Promoting Physical Activity With the OSNAP Initiative
P
articipation in daily physical activity is associated with better cardiovascular and metabolic disease risk profiles and improved mental and physical health among children and youth.1 However, most children and adolescents do not meet nationally recommended levels of physical activity.2 While evidence indicates that interventions can promote physical activity during the school day,3 limited conclusive research has been performed to determine how best to increase physical activity in the hours after school.4-6 Several randomized clinical trials have examined the effect of creating new physical activity–focused after-school programs on physical activity and weight status outcomes.4-7 An alternate approach, the one used in this study, focuses on implementing physical activity–promoting strategies in existing afterschool programs.8 More than 10 million children in the United States participate in after-school programs for a mean of 7.4 hours per week, with children of color and low-income children participating at higher rates.9 This time represents an important opportunity to engage participants in the physical activity necessary to meet the national recommendations by adding time into the program schedule for physical activity or by making available time more physically active. Prior randomized clinical trials in existing programs have provided single-sport or singleactivity curriculum and intervention materials and training for existing staff to implement interventions10-12 or added additional activity-specific programming.13 Such strategies may not be feasible if resources and flexibility in programming schedules are limited. More flexible strategies to increase physical activity offerings through staff training show promise for improving physical activity levels among existing after-school program participants. 12,14 Such strategies using existing resources may cost less and may have broader appeal than interventions focused on single sports. In this clusterrandomized controlled trial, we tested whether an organizational change, collaborative learning approach can be implemented in various school and community–based after-school programs.
At a Glance • This cluster-randomized controlled trial examined the effectiveness of the Out of School Nutrition and Physical Activity (OSNAP) Initiative in increasing children’s physical activity levels in 20 existing after-school programs. • There was no effect of the intervention on moderate to vigorous physical activity, but after-school programs participating in the OSNAP Initiative were successful in making existing program time more vigorously active for children. • Compared with control participants, vigorous physical activity levels among intervention participants increased by 36.0%.
ously from mid-October through the end of May. Before randomization, programs were matched on key characteristics obtained from administrative records, including the afterschool program provider, snack provider, physical activity facilities, and school-level racial/ethnic and socioeconomic composition. The study manager (C.M.G.) matched and enrolled programs. After baseline data collection, the programs within each matched pair were randomized to intervention or control (ie, delayed intervention) status by a masked external statistician using a computer-based random number generator. Neither program directors nor study authors were masked to randomization status, whereas data collectors were masked. After-school programs randomized to the control condition were invited to participate in the intervention the following school year (2011-2012). The study was approved by the Harvard T. H. Chan School of Public Health Institutional Review Board and the Boston Public Schools Office of Data and Accountability. Informed consent was obtained for all study participants. Before baseline data collection, researchers (J.L.B., C.M.G., R.M.L., E.L.K., M.E.deB., and J.C.T.) visited the 20 programs at child dropoff or pickup times to distribute active consent letters available in several languages. Parents or guardians gave written permission for children’s participation, and each child provided verbal assent. The full study protocol can be found in Supplement 1.
Intervention
Methods Design and Sample This experimental study was a cluster-randomized controlled trial conducted in 20 after-school programs (10 intervention sites paired with 10 matched control sites) in Boston, Massachusetts, from the fall of 2010 through the spring of 2011. The Figure shows the flow of programs and individual participants in the study. The study investigated changes in physical activity from baseline (September 27 through November 12, 2010) to follow-up (April 25 through May 27, 2011) among children in intervention programs compared with control programs. Eligible after-school programs were identified and recruited to participate in the study through collaboration between study staff (C.M.G.) and local community program providers (eg, Boys & Girls Clubs, the YMCA, and Boston Public Schools). Programs were eligible if they served children 5 to 12 years old, enrolled at least 40 children, and ran continu156
The Out of School Nutrition and Physical Activity (OSNAP) Initiative15,16 works with after-school programs to improve nutrition and physical activity–related practices, environments, and policies using a socioecological model17 and a communitybased participatory research approach.18 The OSNAP Initiative resources and links to research evidence are available online (http://www.osnap.org). The 2 physical activity goals were (1) to include 30 minutes of moderate, fun physical activity for every child every day (including outdoor activity, if possible) and (2) to offer 20 minutes of vigorous physical activity (VPA) 3 times per week. Over a 6-month intervention period, teams from intervention sites (including program directors and staff) were invited to participate in a series of three 3-hour OSNAP Initiative learning collaborative (LC) sessions modeled after existing community partner professional development programs and prior research. 19,20 At LC sessions, teams reviewed reports of physical activity time provided and participation rates at baseline in their programs compared with the
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Figure. Consolidated Standards of Reporting Trials Diagram of the Flow of Individual Participants Through the Study 222 Programs assessed for eligibility 202 Programs excluded 191 Did not meet inclusion criteria 115 Program duration 47 Enrollment size 16 Age of students 13 Other 4 Declined to participate 7 Did not respond
20 Programs randomized (prior to randomization, programs were matched on program partner, snack provider, school-level student demographics, and physical activity facilities)
10 Programs received the intervention (563 students)
10 Programs served as control (580 students)
288 Students consented to participate
308 Students consented to participate
37 Students were excluded 15 Not present during data collection 0 Refused 16 Meter lost or malfunctioned 6 Insufficient valid wear 251 Students had valid baseline outcome data
40 Students were excluded 15 Not present during data collection 3 Refused 12 Meter lost or malfunctioned 10 Insufficient valid wear 268 Students had valid baseline outcome data
69 Students were excluded 40 Not present or left program 1 Refused 7 Meter lost or malfunctioned 21 Insufficient valid wear 182 Students had valid longitudinal outcome data
48 Students were excluded 27 Not present or left program 1 Refused 1 Meter lost or malfunctioned 19 Insufficient valid wear 220 Students had valid longitudinal outcome data
The primary outcome was physical activity measured via accelerometer.
OSNAP Initiative goals. Using tools provided by study staff, after-school teams identified areas for improvement and set action plans to improve program practices, develop relevant policies, and communicate changes to parents and other partners. At LC sessions, program staff members shared progress with other teams and participated in skill development sessions. Program staff members were also offered additional physical activity skill-building sessions. These additional sessions focused on strategies to incorporate physical activity breaks and small-space activities into the program, including training on the Food & Fun After School curriculum,21 recess-focused training by Playworks,22 and SPARK23 training. Between LC sessions, study staff provided intervention programs, with technical assistance and reminders via telephone, newsletter, and email. Sites were invited to apply for up to $200 to support implementation.
Data Collection Data collectors visited each program for 1 week (5 weekdays) at baseline and follow-up to distribute and collect jamapediatrics.com
accelerometers and to observe program activities, including types and amount of physical activity provided. Data collectors recorded the start and end times of activities offered in several predetermined categories, including free active play (ie, free choice of activity) and structured active play (ie, physical activity led by program staff), and indicated how many and what grade levels of children attended each activity and whether the activity was located indoors or outdoors. Child demographic information, including sex, race/ ethnicity, grade, and age, were collected via parent report on consent forms. From the National Oceanic and Atmospheric Association, study staff obtained local weather data on hourly precipitation and temperature for each day of data collection24 and the 30-year mean annual temperature.25 The average daily temperature during data collection periods, percentage deviation from the average annual temperature, and presence of precipitation (yes or no) were documented for each afterschool period between 2 and 6 PM to account for daily weather changes. (Reprinted) JAMA Pediatrics February 2016 Volume 170, Number 2
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Outcome Measures
Statistical Analysis
Child-Level Outcomes Baseline (September to November 2010) and follow-up (April to May 2011) data were collected on the primary outcome measure of the number of minutes of moderate to vigorous physical activity (MVPA) that individual children accumulated overall during the after-school period. Secondary outcomes included (1) VPA minutes and sedentary activity minutes accumulated overall; (2) the number of MVPA, VPA, and sedentary activity minutes accumulated in modified 10-minute bouts (periods of continuous activity intensity, allowing for 2 minutes to fall below intensity threshold)2; and (3) total accelerometer counts during the after-school period. Students wore accelerometers (GT3X/GT1M or MTI/CSA 7164; Actigraph) on their hip on a fitted belt continuously during the after-school period for 5 school days (Monday through Friday) at baseline and at follow-up. Functionality of monitors was verified for each available accelerometer before assignment for research use. Accelerometer counts were collected in 1-minute epochs, and the number of minutes spent in MVPA were estimated with age-specific cut points for children 6 to 18 years old26 used in national surveillance,2 with thresholds of 4 metabolic equivalent counts for MVPA and 6 metabolic equivalent counts for VPA. Less than 100 accelerometer counts per minute was considered sedentary activity. These cut points based on 1-minute epochs demonstrate excellent accuracy in classifying activity levels among children.27 Nonwear periods were defined according to established protocols as 60 consecutive minutes of zero accelerometer counts, allowing for up to 2 minutes below 100 accelerometer counts.28 Implausibly high values (>20 000 counts) were replaced with imputed counts based on the mean of the last and next valid minutes (when ≤10 in succession) or were set to missing (when >10 in succession). Valid minutes were restricted to minutes during the defined after-school period for which data collectors documented students wearing accelerometers, and valid days consisted of at least 1 hour of data collected during program time. Students with 2 or more valid days at both baseline and follow-up were included in the final analysis to be consistent with criteria used in school-based evaluations29 and to ensure nondifferential attrition in the sample by program. Estimates were also calculated using data from all participants, and these results were not appreciably different (eTables 1, 2, and 3 in Supplement 2).
Linear mixed-effects models were used to investigate whether students at participating OSNAP Initiative programs experienced greater increases in accelerometer-derived physical activity levels during the program period compared with those at control programs. The intervention effect was estimated by an interaction term of period (follow-up is 1, and baseline is 0) by intervention (intervention is 1, and control is 0), in addition to period and intervention status main effects. Models were adjusted at the child level for daily minutes monitored; child sex, race/ethnicity, and grade; matched pair indicators at the program level; model of accelerometer worn (to account for potential differences in output between models30,31); and percentage deviation from the average annual temperature and the presence of precipitation at the observation day level. Program-level random intercepts were used to account for the correlation due to clustering of students within programs. A compound symmetry within-person error covariance structure was used to account for nesting of successive daily observations within students.32 The df for significance tests was calculated using the between-within method.33,34 Adjusted means for each outcome at baseline and follow-up were estimated from models adjusting for clustering, monitored minutes, and monitor model only. Post hoc analyses using stratified mixed models examined whether intervention effects differed by sex or grade (kindergarten through 2 vs 3-6). Analyses were performed between March 2014 and August 2015 using statistical software (SAS, version 9.3; SAS Institute Inc). Sample-size calculations completed before this study were based on observed data from children in after-school programs. They suggested that, with 30 participants clustered within 10 matched intervention and control programs, assuming an intraclass correlation of children’s physical activity minutes within programs of 0.01 and a correlation of 0.6 between baseline and follow-up physical activity minutes, researchers would have 80% power to detect a mean (SD) difference of 4.6 (19.7) minutes of MVPA as a primary outcome. Standard deviations were based on data collected in 4 pilot sites.
Program-Level Outcomes The mean daily minutes offered to the typical child for each type of activity were calculated by summing the number of minutes recorded by data collectors in the daily log, weighted by the proportion of children present at the program who were attending the particular activity. Researchers calculated the number of days on which programs provided at least 30 minutes of physical activity time to all attendees. The mean program-level physical activity minutes offered per day were calculated for baseline and follow-up, and changes by condition were compared, accounting for clustering of days within programs. 158
Results OSNAP Initiative Exposure and Participation Staff from all intervention programs attended LC sessions 1 and 2, and 9 of 10 programs participated in LC session 3. All intervention programs included the goal of increasing physical activity in their action plans. Nine of 10 intervention programs included practice, policy, or communication actions for providing 30 daily minutes of physical activity time for every child (including outdoor activity, if possible) as part of their action plans, and 6 of 10 intervention programs reported completing all specified actions. Intervention program staff attended additional physical activity skill training, including SPARK (2 programs), Food & Fun After School (4 programs), and Playworks (7 programs). On monthly reports, 5 intervention programs and 1 control program reported ever using a Food & Fun After School physical activity lesson. One intervention pro-
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Original Investigation Research
Table 1. Demographics of Participants Attending After-School Programs in the OSNAP Initiative Cluster-Randomized Controlled Trial Participating Childrenb Consenting Children (n = 596)a
All (n = 402)
Intervention (n = 182)
Control (n = 220)
Male
303 (50.8)
196 (48.8)
85 (46.7)
111 (50.5)
Female
293 (49.2)
206 (51.2)
97 (53.3)
109 (49.5) 22 (10.0)
Variable Sex, No. (%)
Race/ethnicity, No. (%) White non-Hispanic
55 (9.2)
30 (7.5)
8 (4.4)
Black non-Hispanic
192 (32.2)
123 (30.6)
44 (24.2)
79 (35.9)
Hispanic/Latino
196 (32.9)
140 (34.8)
68 (37.4)
72 (32.7)
Asian
25 (4.2)
13 (3.2)
9 (4.9)
4 (1.8)
128 (21.5)
96 (23.9)
53 (29.1)
43 (19.5)
78 (13.1)
53 (13.2)
27 (14.8)
26 (11.8)
Abbreviation: OSNAP, Out of School Nutrition and Physical Activity.
1
94 (15.8)
69 (17.2)
27 (14.8)
42 (19.1)
a
2
119 (20.0)
84 (20.9)
32 (17.6)
52 (23.6)
3
103 (17.3)
71 (17.7)
33 (18.1)
38 (17.3)
Consenting children were children enrolled at 20 after-school programs and consenting to participate in the study.
4
105 (17.6)
68 (16.9)
29 (15.9)
39 (17.7)
b
5
83 (13.9)
46 (11.4)
25 (13.7)
21 (9.5)
6
14 (2.3)
11 (2.7)
9 (4.9)
2 (0.9)
7.9 (1.8)
7.6 (1.6)
Participating children were all children at 20 after-school programs who provided at least 2 weekdays of valid accelerometer data per data collection period.
Other or unknown Grade, No. (%) Kindergarten
Age, mean (SD), y
7.8 (1.8)
7.7 (1.7)
gram used 4 Food & Fun After School activities. Five of 10 intervention programs applied for and received $200 to support implementation of their physical activity action planning goals.
Participants Twenty programs agreed to participate and be randomized to intervention or control (ie, delayed intervention) status. Approximately half of the program participants assented to participate in both intervention (51.2% [288 of 563]) and control (53.1% [308 of 580]) programs. Of the 251 students (87.2% [251 of 288]) in intervention programs and 268 students (87.0% [268 of 308]) in control programs with valid baseline accelerometer data, longitudinal analysis of change in accelerometerderived physical activity was conducted among 182 intervention participants (72.5% [182 of 251] retention) and 220 control participants (82.1% [220 of 268] retention). Participants were racially/ethnically diverse (Table 1). Approximately half were female (51.2% [206 of 402]), and students ranged from kindergarten through grade 6, with a mean age of 7.7 years. Children provided means of 4.2 days of physical activity data at baseline and 4.0 days at follow-up, with mean daily monitored times of 139.9 minutes at baseline and 142.5 minutes at follow-up (Table 2).
Program-Level Outcomes At baseline, intervention sites provided 30 or more minutes of physical activity on a mean (SD) of 2.3 (1.6) days compared with a mean (SD) of 3.2 (1.9) days provided by control sites (P = .27). Change in physical activity minutes offered to children during program time from baseline to follow-up was not significantly different between conditions (−1.2; 95% CI, −14.2 to 12.4; P = .87). Table 2 summarizes the types and locations jamapediatrics.com
of physical activity time provided by programs during observed days at baseline and follow-up.
Child-Level Outcomes Adjusting for the matched design and other variables, the intervention led to no significant change in MVPA minutes overall (P = .40) or in bouts of MVPA (P = .92) during program time (Table 3). However, participants in intervention programs increased VPA minutes per day (3.2; 95% CI, 1.8-4.7; P < .001) and VPA minutes per day in bouts (4.1; 95% CI, 2.7-5.6; P < .001) during program time relative to participants in control programs. No significant differences were observed in changes in total (P = .57) or modified bouts (P = .35) of sedentary activity time among intervention program participants compared with control participants. However, there were significant increases in total accelerometer counts per day (16 894; 95% CI, 5101-28 686; P = .005) among intervention participants compared with control participants. Subsequent stratified analyses by groupings of kindergarten through grade 2 and grades 3 through 6 suggested a differential intervention effect on overall MVPA and VPA. Among younger participants, the intervention was associated with an increase in MVPA minutes during program time (3.9; 95% CI, 0.5-7.2; P = .02) compared with controls, while it was associated with a decrease in MVPA minutes among older participants (−6.7; 95% CI, −9.9 to −3.6; P < .001). Among younger participants, the intervention was associated with an increase in VPA (4.8; 95% CI, 2.8-6.9; P < .001) compared with controls. Among older participants, the observed increase in VPA associated with the intervention was not statistically significant (1.5; 95% CI, −0.6 to 3.5; P = .17). Intervention effects did not differ significantly by participant sex. (Reprinted) JAMA Pediatrics February 2016 Volume 170, Number 2
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Table 2. Observed Characteristics of Participants Attending After-School Programs in the OSNAP Initiative Cluster-Randomized Controlled Trial Baseline (September to November 2010) Variable
All (n = 402)
Follow-up (April to May 2011)
Intervention (n = 182)
Control (n = 220)
179 (98.4)
219 (99.5)
All (n = 402)
Intervention (n = 182)
Control (n = 220)
Actigraph Accelerometer Model, No. (%) MTI/CSA 7164
398 (99.0)
0
0
0
GT1M
0
0
0
148 (36.8)
71 (39.0)
77 (35.0)
GT3X
4 (1.0)
3 (1.6)
1 (0.5)
254 (63.2)
111 (61.0)
143 (65.0)
Accelerometer Wear, mean (SD) Monitored time, d Daily monitored time, min
4.2 (1.0)
4.3 (0.9)
4.1 (1.0)
4.0 (1.0)
4.0 (1.0)
4.1 (1.0)
139.9 (33.4)
142.8 (33.9)
137.4 (32.7)
142.5 (33.2)
144.0 (35.4)
141.2 (31.3)
Physical Activity Time Offered per Day by Programs, mean (SD), min All physical activity
42.2 (19.6)
36.6 (18.4)
46.9 (19.4)
66.1 (20.6)
61.4 (23.3)
70.0 (17.1)
Outdoor physical activity
20.3 (23.0)
12.7 (11.8)
26.5 (27.7)
37.6 (22.0)
26.8 (16.6)
46.5 (22.1)
Indoor physical activity
22.0 (17.3)
23.9 (17.0)
20.4 (17.4)
28.6 (20.0)
34.6 (23.5)
23.6 (14.9)
Free play physical activity
25.8 (16.7)
21.7 (10.3)
29.2 (20.0)
45.2 (21.3)
41.5 (21.9)
48.4 (20.3)
Structured physical activity
16.4 (11.6)
15.0 (10.9)
17.7 (12.0)
20.9 (15.0)
19.9 (11.7)
21.7 (17.2)
Free indoor activity
11.4 (11.2)
13.5 (10.9)
9.7 (11.2)
15.9 (16.1)
20.0 (19.9)
12.4 (11.0)
Free outdoor activity
14.4 (19.0)
8.2 (9.1)
19.5 (23.1)
29.4 (21.0)
21.4 (14.0)
35.9 (23.5)
Structured indoor activity
10.5 (8.7)
10.4 (8.9)
10.6 (8.5)
12.7 (10.0)
14.6 (10.6)
11.1 (9.3)
5.9 (9.0)
4.6 (5.0)
8.2 (12.0)
5.4 (5.6)
10.5 (15.0)
By location
Free play or structured activitya
By location and structure
Structured outdoor activity
7.0 (11.2)
Weather, mean (SD) Average daily temperature, °F
58.4 (8.4)
57.0 (8.3)
59.5 (8.3)
61.2 (6.6)
61.2 (6.4)
61.2 (6.8)
% Deviation from the average annual temperature, °F
13.3 (16.3)
10.7 (16.2)
15.5 (16.1)
18.9 (12.9)
18.9 (12.5)
18.9 (13.2)
1.3 (0.9)
1.3 (0.9)
1.2 (1.0)
1.8 (1.0)
1.8 (0.9)
1.8 (1.0)
Precipitation, d
Abbreviation: OSNAP, Out of School Nutrition and Physical Activity. a
Free play identifies activity choices that are chosen by children while structured activity identifies opportunities during which program staff choose and lead activity for children.
Discussion Children in programs participating in the OSNAP Initiative increased VPA levels by 36.0%, or an estimated 3.2 minutes per day during the program period overall, and 4.1 minutes in bouts of VPA. Overall, the programs participating in the OSNAP Initiative did not make significant changes in time allotted for physical activity compared with controls but were successful in making existing time more vigorously active for children. Evidence among youth indicates that engaging in VPA may be associated with better fitness, academic achievement, and cognition and with lower adiposity and cardiovascular risk compared with engaging in moderate physical activity.1,35,36 While older students participating at OSNAP Initiative program sites did not increase MVPA, there was evidence that implementing the intervention was effective in increasing overall MVPA among younger program participants. Potentially, the technical assistance and tools and resources used were more applicable and appropriate to younger children. Activity patterns and preferences may change with age. Identification of program policies, practices, and communication strategies for engaging older students may be needed to achieve equitable results in these grades. 160
The observed relative increase in VPA per child (4.1 minutes) is similar to that in a meta-analysis5 of after-school program initiatives promoting physical activity and is consistent with changes seen in more recent studies of interventions adding specific programmed physical activities,37 using train-thetrainer approaches for soccer-focused activity promotion,10 and building programmatic capacity through staff skill development12 in existing program settings. The OSNAP Initiative provided technical assistance and training for existing program staff, with directed quality improvement goals that focused on improving the policies, practices, and communication strategies used in everyday program operation. The OSNAP Initiative was designed with a focus on policy and environmental changes that programs with varying existing resources could implement within existing structures to maximize sustainability. This approach was used successfully with both school-based and community-based programs. Nationally, approximately 57% of after-school participants attend school-based programs.9 This cluster-randomized controlled trial used a community-based approach that engaged after-school leaders and program providers in development and implementation. It also assessed changes in physical activity using objective assessment measures. Researchers used established accelerometer
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Table 3. Effect of the OSNAP Initiative on Children’s After-School Physical Activity Levels Among Participants
Variable
Mean (SE)a
Mean
Baseline
Crude Changea
Follow-up
Intraclass Correlation Coefficienta,c
Adjusted Changeb Value (95% CI)
P Value
MVPA overall, min Intervention
23.8 (3.7)
32.5 (3.8)
8.7
0.13
Control
30.4 (3.7)
39.6 (3.8)
9.2
NA
−1.0 (−3.3 to 1.3) NA
.40 NA
MVPA in bouts, min Intervention
11.6 (4.1)
19.8 (4.2)
8.2
0.13
Control
18.9 (4.1)
26.7 (4.2)
7.7
NA
0.1 (−2.5 to 2.8) NA
.92 NA
VPA overall, min Intervention
8.9 (2.2)
12.1 (2.3)
3.2
13.7 (2.2)
13.5 (2.3)
−0.2
Intervention
3.1 (1.9)
4.6 (2.0)
1.5
Control
7.3 (1.9)
4.7 (2.0)
−2.6
Control
0.12
3.2 (1.8 to 4.7)
NA
NA
